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St Luke's Hospice
Equal Opportunities Monitoring Form
St Luke's Hospice seeks to employ a workforce that reflects the diverse community at large. The hospices objective is to ensure that no job applicant or employee receives less favourable treatment, directly or indirectly, on the grounds of race, gender, sexual orientation, marital status, religion, age, disability, ethnic or national origin.
To monitor the effectiveness of our equal opportunities policy, we would like you to provide the following information. The form is designed only to monitor our ability to attract candidates with an appropriate range of age, race, gender and ability, not other characteristics. This information is detached from your application before it is considered, and stored separately. Consequently we do not ask for your name.
This is a Microsoft Word template. Please click in the grey boxes and enter your answer as appropriate. Then save the result as a Word document file and send it as an e-mail attachment with your employment application form to:
personnel@stlukes-hospice.org.
1. What is your gender? FORMDROPDOWN (choose from the drop-down menu)
Which age group are you in? FORMDROPDOWN (choose from the drop-down menu)
Please indicate your ethnic group by checking only the appropriate box (categories are based on the 2001 Census):
Black White
Black British FORMCHECKBOX British FORMCHECKBOX
Caribbean FORMCHECKBOX Irish FORMCHECKBOX
African FORMCHECKBOX Any other wh i t e b a c k g r o u n d F O R M C H E C K B O X
A n y o t h e r B l a c k b a c k g r o u n d F O R M C H E C K B O X ( p l e a s e s t a t e F O R M T E X T )
( p l e a s e s t a t e F O R M T E X T )
A s i a n M i x e d
A s i a n B r i t i s h F O R M C H E C K B O X B l a c k C a r i b b e a n & W h i t e F O R M C H E C K B O X
I n d i a n FORMCHECKBOX Black African & White FORMCHECKBOX
Bangladeshi FORMCHECKBOX Asian & White FORMCHECKBOX
Pakistani FORMCHECKBOX Any other mixed background FORMCHECKBOX
Any other Asian background: FORMCHECKBOX (please state FORMTEXT )
( p l e a s e s t a t e F O R M T E X T )
C h i n e s e o r o t h e r e t h n i c g r o u p
C h i n e s e F O R M C H E C K B O X
V i e t n a m e s e F O R M C H E C K B O X
A n y o t h e r F O R M C H E C K B O X
( p l e a s e s t a t e F O R M T E X T )
( C o n t i n u e d o n t h e n e x t p a g e ) A d i s a b i l i t y o r h e a l t h p r o b l e m does not preclude full consideration for the job, and applications from suitable people with disabilities are welcome.
Disability is defined as any physical or mental impairment, which has a substantial and long-term adverse effect on a persons ability to carry out normal day-to-day activities.
Do you consider that you have a disability? FORMDROPDOWN (choose from the drop-down menu)
4. If yes, are you registered? FORMDROPDOWN (choose from the drop-down menu)
5. Please describe a 8
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