Annex A

Monitoring Information

Monitoring information is not used in the short listing process and will not be seen by the panel assessing your application.  

Candidates’ 								Candidates’ 
Name:									Postcode	

Date of birth

Gender	
	Male			Female		

Ethnic Origin

White		Black		Asian/Asian British		Chinese		Mixed		
British		African		Bangladeshi		Chinese		Asian & white		
										
Irish		Caribbean		Indian		Any other ethnic background 		Black African & white		
										
Any other white background		Any other black background 		Pakistani						
								Black Caribbean & white		
				Any other Asian background 						

								Any other mixed background 		

Disability

Many people do not consider themselves to be disabled, but under the Disability Discrimination Act you can consider yourself disabled if you have a physical or mental impairment or long term health condition, and the effects are expected to last, or have lasted for a year or longer, and have a substantial effect on your ability
to carry out day to day activities; or your day to day activities would be limited without medication, treatment or adjustments (for example the use of inhalers, physiotherapy, a hearing or visual aid or insulin).

Taking this into account, do you consider yourself to be a disabled person?

No			Yes		

If you are disabled and in receipt of benefits you need to be aware that under current regulations, if you are remunerated for an appointment it may affect your entitlement.