SWC Robotics and Automation Part Time Academy 2024/26 Cohort 2 - Applicant Equality Monitoring Form

1. COMMUNITY BACKGROUND

(Required) I am a member of the Protestant Community I am a member of the Roman Catholic Community I am not a member of either the Protestant or the Roman Catholic communities I prefer not to say

2. ETHNIC GROUP

(Required) White Chinese Irish Traveller Roma Indian Filipino Black African Black Other Mixed ethnic group (please state which) Any ethnic group not mentioned above (please state which) I prefer not to say

Mixed or other ethnic group

3. COUNTRY OF BIRTH

What is your country of birth?

I prefer not to say

4. AGE

What is your date of birth?

Day (dd)
-

Month (mm)
-

Year (yyyy)

I prefer not to say

5. GENDER IDENTITY

What best describes your gender identity?

(Required) Male Female Non-binary I prefer to self-describe as (please state below) I prefer not to say

Self described gender identity

6. SEXUAL ORIENTATION

Please indicate your sexual orientation by ticking the appropriate box below:

(Required) I am straight (heterosexual) I am gay or lesbian I am bisexual I prefer to self-describe as (please state below) I prefer not to say

Self described sexual orientation

7. MARITAL OR CIVIL PARTNERSHIP STATUS

Please indicate your marital or civil partnership status.

(Required) Single (never married or in a civil partnership) Married or in a civil partnership Separated (but still married or in a civil partnership) Divorced, or formerly in a civil partnership that is now legally dissolved Widowed, or surviving partner from a registered civil partnership I prefer not to say

8. DEPENDANTS AND CARING RESPONSIBILITIES

Do you have dependants or caring responsibilities for family members or other persons?

(Required) Yes No I prefer not to say

If you answered “yes”, are your dependants or the people your look after (you may tick more than one box)

A child or children A disabled person or persons An elderly person or persons If 'other', please describe who you care for

Other - please specify if not listed above

9. DISABILITY

Are your day-today activities limited because of health problems or disability which has lasted or is expected to last at least 12 months?

(Required) Yes No I prefer not to say

If you answered “yes”, please indicate the nature of your impairment by ticking the appropriate box or boxes below.

Physical impairment, such as difficulty using your arms, or mobility issues requiring you to use a wheelchair or crutches Sensory impairment, such as being blind or having a serious visual impairment, or being deaf or having a serious hearing impairment Mental health condition, such as depression or schizophrenia Learning disability or difficulty, such as Down’s Syndrome or dyslexia, or cognitive impairment, such as Autistic spectrum disorder Long-standing or progressive illness or health condition, such as cancer, HIV infection, diabetes, epilepsy or chronic heart disease Other (please specify) I prefer not to say

Other disability or impairment

SWC Robotics and Automation Part Time Academy 2024/26 Cohort 2 - Applicant Equality Monitoring Form

EQUALITY MONITORING FORM