EQUALITIES MONITORING:
DATA COLLECTION FORM.
The data provided on this form does not form part of the recruitment and
selection process. We are an equal opportunities employer. Our aim in
collecting this information is to ensure we are doing what we can to
encourage applicants across all demographic groups. This information
can support us to continue to learn to what degree we are achieving this
and guide us in what more we need to do better in future. If you are
comfortable to do so, please share the following information.
Age:
[ ] Prefer not to say
[ ] 18-24
[ ] 25-34
[ ] 35-44
[X] 45-54
[ ] 55-64
[ ] 65-74
[ ] 75+
Disability
Do you have a disability?
[ ] Prefer not to say
[ ] Yes, I am aware I have a disability
[X] No, I don’t have a disability
[ ] As far as I’m aware, I don’t have a disability.
You will be considered as having a disability for discrimination purposes if
you fit the definition as given in the Equality Act 2010. In the Act, a
disability is a ‘physical or mental impairment which has a substantial and
long-term adverse effect on a person’s ability to carry out normal day to
day activities.’ For these purposes, ‘long term’ is taken to mean the
condition is likely to last longer than 12 months or likely to recur.
Ethnicity
[ ] Prefer not to say
Asian or Asian British
[ ] Bangladeshi
[X] Indian
[ ] Pakistani
[ ] Other Asian background, please specify
_________________________________
Black or Black British
[ ] African
[ ] Caribbean
[ ] Other Black background, please specify
__________________________________
Chinese and other groups
[ ] Chinese
[ ] Other ethnic group, please specify
_______________________________________
Mixed race
[ ] White and Asian
[ ] White and Black African
[ ] White and Caribbean
[ ] Other Mixed background, please specify
___________________________________
White
[ ] British
[ ] Irish
[ ] Welsh
[ ] Other white background, please specify
____________________________________
Religion or belief
[ ] Prefer not to say
[ ] Buddhist
[ ] Christian
[ ] Hindu
[ ] Jewish
[X] Muslim
[ ] Sikh
[ ] Other, please specify _________________________________________________
[ ] No religion
Gender Identity
Which of the following options best describes how you think of yourself.
[ ] Woman (including trans women)
[X] Man (including trans man)
[ ] Non-binary
[ ] In another way.
Is your gender identity the same as the gender you were assigned at
birth?
[X] Yes
[ ] No
[ ] Prefer not to say.
Sexual orientation
[ ] Prefer not to say
[ ] Lesbian
[ ] Gay man
[ ] Bisexual
[X] Heterosexual
[ ] Asexual
[ ] Pansexual
End of equal opportunities monitoring form.
Data Protection Statement
Data controller: CVS South Gloucestershire.
The organisation uses this information to review compliance with its
policies on equal opportunity in relation to recruitment. We will use this
data to inform our statistics on the representation of the categories of
individual as shown above. We will treat all personal information in line
with current data protection legislation and our data protection policy. For
more information on how we use the information you have provided,
please see our privacy notice for job applicants which is contained within
the candidate pack, which was provided with this form. In order for us to
process this information and to comply with data protection legislation, we
require your consent. You are not required to give your consent; you
acknowledge that any consent given is freely given. Your job application is
not dependent on your giving consent to our processing of this data.
Signature: Nasirul Haque
Date: 20/06/2025