Monitoring Form

Applicant Re f No CRP/10/11/
(for office use only)
MONITORING FORM
(Note: The Recruitment Panel will not have access to this information)
1 Community Background
Protestant Roman Catholic Neither Protestant or Roman Catholic
2 Gender MALE FEMALE
3 Marital Status
Married Single Divorced Separated Widowed
Other
(Please specify) _____________________________
4 Date of Birth dd/mm/yyyy _____________________________
5 Caring Responsibilities
None Children Elderly Relative(s)
Other
(Please specify) _____________________________
6 EU National
Do you require a work permit to work in the UK Yes No
7 Disability
Under the Disability Discrimination (NI) Act 1995 a disabled person is defined as a person with: “A
physical or mental impairment which has a substantial or long term adverse effect on their ability to carry
out normal day to day activities”.
Do you meet (or have you in the past, met) this definition Yes No
If yes, please tick the heading which best describes your disability.
Mobility Mental Vision Learning
Hearing Speech Dexterity/Co-Ordination
Please state what reasonable adjustments, provisions or facilities may be required in the Selection Process.
____________________________________________________________________________________
____________________________________________________________________________________

8 Ethnic Origin
Black African Bangladeshi Black Caribbean Chinese
Indian Irish Traveller Pakistani White
Mixed Race Other (Please specify) _______________________