Diversity Monitoring Form

While you are not obliged to complete this questionnaire, or any part of it, providing the information requested below will assist us in monitoring the implementation of diversity at UCLan Students’ Union. The information that is provided will be treated as strictly confidential, is used for statistical analysis only and will be processed in accordance with the Data Protection Act 1998.

Position applied for:
Date Applied Date Applied / MM / DD YYYY
Where did you first see/hear about this vacancy
Which of the following best describes your gender identity?

Which of the following best describes your gender identity? Man Woman In another way (please describe [optional]) Prefer not to say
Does the gender you live in match the gender you were assigned at birth?

Does the gender you live in match the gender you were assigned at birth? Yes No Prefer not to say
Marital status

Marital status Married/In a Civil Partnership Partner Single Other Prefer not to say
Age band

Age band Under 21 21–24 25–29 30–39 40–49 50–59 60–65 Over 65 Prefer not to say
How do you define your sexual orientation?

How do you define your sexual orientation? Heterosexual/Straight Gay/Lesbian Bisexual/Bi Queer In another way (please describe [optional]) Prefer not to say
Do you consider yourself to have a specific learning disability, other disability, impairment, long-term illness or health condition?

Do you consider yourself to have a specific learning disability, other disability, impairment, long-term illness or health condition? Yes No Don’t Know Prefer not to say
Please describe your disability, impairment or long-term health condition. Please select all that apply.

Please describe your disability, impairment or long-term health condition. Please select all that apply. Physical impairment such as using a wheelchair to get around and/or mobility difficulties Blind or partially sighted Deaf or hard of hearing Mental health difficulties e.g. depression, schizophrenia Learning difficulty where a person learns in a different way e.g. dyslexia, dyspraxia Profound and/or multiple learning difficulties Autistic Spectrum Disorder An unseen disability or health condition e.g. diabetes, epilepsy, asthma, HIV Prefer not to say No known disability, impairment or long-term health condition
Ethnicity:

White

Ethnicity:

White English/Welsh/Scottish/Northern Irish/British Irish Gypsy/ Traveller Any other White background
Mixed/Multiple ethnic groups

Mixed/Multiple ethnic groups White and Black Caribbean White and Black African White and Asian Any other Mixed/Multiple ethnic background
Asian/Asian British

Asian/Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background
Black/African/Caribbean/Black British

Black/African/Caribbean/Black British Caribbean African British Any other Black/African/Caribbean/Black British background
Other ethnic group

Other ethnic group Arab Any other ethnic group, please describe Prefer not to say
Religion, Faith and Belief:

Religion, Faith and Belief: Buddhist Christian (including Catholic, Church of England, Church of Scotland, Protestant and all other Christian denominations) Hindu Jewish Muslim Sikh Spiritual Agnostic Atheist Any other religion or belief (Please specify) Pagan Prefer not to say