Cyfannol Women’s Aid wants to eliminate discrimination and promote equal opportunities, and collecting the following information can help us to achieve this. We monitor and analyse diversity information to make sure that our processes are fair, transparent and promote equality of opportunity for all service users, staff and job applicants.  It would therefore be appreciated if you could complete this Equal Opportunities Monitoring form. 
 
Completion is voluntary and the information will be kept anonymous and confidential.  The information will be collated periodically for monitoring and statistical purposes, and reported to the organisations that provide us with funding, and to our Board of Trustees.  Any information provided on this form will be treated in accordance with the General Data Protection Regulations.
 
Our Privacy Notice will tell you more about how and why we use this information.  Please contact our People Services Team if you would like a copy.

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* 1. Date

Date

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* 2. What area is the position you are applying for/work in?

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* 3. Are you:

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* 4. What is your sex?

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* 5. Is the gender you identify with the same as your sex registered at birth?

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* 6. Which of the following best describes your sexual orientation?

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* 7. What is your age group?

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* 8. What is your main language?

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* 9. How well can you speak English?

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* 10. Can you understand, speak, read or write Welsh?  (Please tick all that apply)

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* 11. What is your legal marital or registered civil partnership status? 

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* 12. What is your religion?

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* 13. How would you describe your national identity? 

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* 14. How would you describe your ethnic group?

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* 15. How is your health in general?

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* 16. Do you have any physical or mental health conditions, illnesses or impairments lasting, or expected to last, 12 months or more? 

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* 17. Do any of your conditions, illnesses or impairments reduce your ability to carry out day-to-day activities? 

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* 18. It helps us to know whether we are reaching all disabled people.  If you ticked “yes” above, please can you tick the relevant box(es) below.  You are welcome to tick more than one box if appropriate. 

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* 19. Do you have any dependent children? 

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* 20. Do you look after, or give any help or support to anyone because they have long term physical or mental health conditions, illnesses, impairments or problems?  

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* 21. I do not wish to provide any of the information requested on this form 

If you require this form in another language or format, or need assistance in completing this form, please contact: the People Services Team, Cyfannol Women’s Aid, 3 Town Bridge Buildings, Pontypool, NP4 6JE

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