PRIVATE & CONFIDENTIAL

EQUAL OPPORTUNITIES MONITORING FORM

Birmingham City University is committed to promoting Equal Opportunities and seeks to prevent any
form of unlawful or unfair discrimination. The information you provide here will be recorded and
processed on our HR database and will be used for monitoring purposes only. It will not form part of
the recruitment process and will be detached from your application. All information you provided
will be treated in the strictest confidence and will be processed in accordance with the Data
Protection Act 1998.

First Name: Benjamin Surname: Adams

Previous Surname (if applicable):
Job Title: Student
Reference Number: Date of Birth: 29/11/2000

Please tick here if you do not wish to complete this section.

Are you: Male Female (Please tick)

White:

11 White British

12 White Irish

19 Other White Background (Please specify) ________________________

Black or Black British

21 Black or Black British – Caribbean

22 Black or Black British – African

29 Other Black background (Please specify) ________________________

Asian or Asian British

31 Asian or Asian British - Indian

32 Asian or Asian British - Pakistani

33 Asian or Asian British - Bangladeshi

34 Chinese

39 Other Asian background (Please specify) ________________________

Mixed

41 Mixed - White and Black Caribbean

42 Mixed - White and Black African

43 Mixed - White and Asian

49 Other Mixed background (Please specify) ________________________

Other

80 Other Ethnic background

90 Not known

98 Information refused

Sexual Orientation

01 Bisexual

03 Gay Woman/Lesbian

04 Heterosexual

05 Other (Please specify) ________________________

98 Information refused

Religion

01 No religion

04 Christian/Church of Scotland

06 Christian - Presbyterian Church in Ireland

07 Christian - Church of Ireland

08 Christian - Methodist Church

09 Christian - other denomination

11 Jewish

13 Sikh

14 Spiritual

80 Other religion or belief (Please specify) ________________________

98 Information refused

What is your Nationality? British__________________________________________

Disability

Please read the definition of disability below and confirm whether you consider yourself to be covered by the definition:

Yes No Prefer not to say

THE DEFINITION OF 'DISABILITY' UNDER THE EQUALITY ACT 2010

In the Act a person has a disability if they have a physical or mental impairment that has a substantial and long-term
adverse effect on their ability to perform normal day to day activities. For the purposes of the Act, these words have the
following meanings:
 • 'substantial' means more than minor or trivial
• 'long term' means that the effect of the impairment has lasted or is likely to last for at least 12 months
(there are special rules covering recurring or fluctuating conditions)
• 'normal day to day activities' include everyday things like eating, washing, walking and going shopping

People who have had a disability in the past that meets this definition are also protected by the Act. There are additional
provisions relating to people with progressive conditions. People with HIV, cancer or multiple sclerosis are protected by the
Act from the point of diagnosis. People with some visual impairments are automatically deemed to be disabled.

If you have answered yes please indicate the nature of your disability: (please tick as appropriate)

Specific learning disability (such as Dyslexia or Dyspraxia)

General learning disability (such as Downs Syndrome)

Cognitive impairment (such as autistic spectrum disorder or resulting from head injury)

Long standing illness or health condition (such as cancer, HIV, chronic heart disease, epilepsy or diabetes)

Mental health condition (such as depression, schizophrenia)

Physical impairment or mobility issues (such as difficulty using arms or wheelchair user)

Deaf or serious hearing impairment D Blind or serious visual impairment D Other type of disability

If you have selected 'Other type of disability' or wish to provide further information please provide details below:

Declaration

I understand that the information I have provided will be recorded and processed on the HR database in accordance with
the Data Protection Act 1998.

Signed: _______ Dated: 14/03/2022

Please return this completed questionnaire with the other associated forms. Thank you.