Author: Test
Last saved by: Charlotte Fowles
Company: Department of Health

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.