Equality and Diversity monitoring form

  • Severn Hospice wants to meet the aims and commitments set out in its Equality and Diversity Policy. To assist the hospice in meeting this aim, we need to monitor the equality and diversity profile of the workforce. We also need to ensure that we fully comply with the Equality Act 2010. The act sets out nine protected characteristics – age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. This form is voluntary and will not be used as part of the selection process nor will it be seen by anybody who is interviewing you. The information collected is only used for monitoring purposes in an anonymised format to assist the organisation in analysing the profile and make up of individuals who apply, are shortlisted and appointed to each vacancy. Should you not wish to complete this form your application will not be prejudiced in any way.

    You can save this form for 30 days and continue filling it in later by clicking ‘save and continue’ at the bottom of this page.

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  • Ethnic group

  • A disabled person is defined in the Equality Act 2010 as someone with a physical or mental impairment that has a substantial and long-term impact on their ability to carry out day to day activities. Examples are: mobility, manual dexterity, speech, hearing, seeing and memory. The definition also covers HIV, multiple sclerosis and cancer from the time of diagnosis, and progressive conditions from the point at which they have an impact on day to day activities. The Hospice will consider making such adjustments as are reasonable in compliance with the Equality Act 2010.

  • Declaration

    The information you provide on this form will be used in anonymised form for the hospice to internally record and monitor its progress against a number of indicators of workforce equality. I agree to the use of my personal information as explained above.

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  • Thank you for completing this form.


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