SOUTH BELFAST

EQUAL OPPORTUNITIES MONITORING FORM 
(In strictest confidence)

Application ref no: __________
1. Perceived Religious Affiliation:

I am a member of the: 

Protestant Community		Catholic Community	

Neither the Protestant or the Catholic Community	

2. Gender:

I am FEMALE 		MALE  

3. Marital Status/Civil Partnership Status:

Are you married or in a civil partnership?

YES		NO

4. Disability:

In line with the Disability Discrimination Act 1995, a disability is defined as “a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day to day activities”
Having read this definition do you consider yourself to have a disability?

YES 		NO 

5. Age Band:

16-20 		21-30 		31-40 		41-50 		51-60		61-65+ 

6. Cultural/Ethnic Origin;

Chinese			Traveller

Indian			Black/African – Caribbean

Pakistani		White

Other Asian		Other (please specify) ___________________________

7. Sexual Orientation:
Please indicate your sexual orientation by ticking the appropriate box below:
My Sexual Orientation is towards:
Persons of a different sex to me: (i.e. I am a heterosexual man or woman)
Persons of the same sex as me: (i.e. I am gay man or a lesbian)
Persons of both sexes: (i.e. I am bisexual man or woman)
Prefer not to say