Recruitment Monitoring Form

Recruitment Monitoring Form

CONFIDENTIAL
Name*

Title(s)First NameLast Name
Application for the position of:*
Note: the options provided below for ethnicity and disability conform to current HESA Staff Return Requirements.

1. What is your ethnic group?
Please select an option from the below list; further options will then appear, depending on which you select.*

WhiteMixedAsian or Asian-BritishBlack or African or CaribbeanOther groupPrefer not to say
Please select from the following:*

White BritishWhite ScottishIrish TravellerGypsy or TravellerOther
Please select from the following:*

White/ Black CaribbeanWhite/ Black AfricanWhite/ AsianOther
Please select from the following:*

Asian or Asian-British IndianAsian or Asian-British BangladeshiAsian or Asian-British PakistaniChineseOther Asian Background
Please select from the following:*

Black or Black-British AfricanBlack or Black-British CaribbeanOther Black Background
Please select from the following:*

ArabOther Ethnic Background
2. Gender*

MaleFemalePrefer not to sayOther
3. Age Group*

16 - 2526 - 3536 - 4546 - 5556 - 6566 - 70Over 70Prefer not to say
4. Disability - Do you consider yourself to have a disability or a long-term health condition?*

YesNoPrefer not to say
Please indicate which in the boxes below.

Two or more impairments and/or disabling medical conditionsA social/communication impairment such as Asperger's syndrome/other autistic spectrum disorderA specific learning difficulty such as dyslexia, dyspraxia or AD(H)DA longstanding illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsyDeaf or serious hearing impairmentA physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutchesGeneral learning disability (such as Down's syndrome)A mental health condition, such as depression, schizophrenia or anxiety disorderBlind or a serious visual impairment uncorrected by glassesA disability, impairment or medical condition that is not listed aboveInformation refused
5. Nationality*
Declaration

You are required to declare any pending criminal prosecutions they may have as well as any spent criminal convictions, cautions, reprimands and final warnings as defined under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. The only exception to this requirement is that you do not need to disclose any ‘protected’ cautions, or convictions as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013. Having a criminal record will not necessarily bar you from working with us. This will depend on the nature of the position and the circumstances and background of any offences.
Do you have anything to declare?*

YesNo
I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my dismissal.
Signature*

Clear
Data protection - privacy notice

All of the information collected in this form is necessary and relevant to the performance of the job applied for. We will use the information provided by you on this form and by the referees you have noted for recruitment purposes only. The Foundation will treat all personal information with the utmost confidentiality and in line with current data protection legislation. We rely on the lawful basis of legitimate interest to process the information provided by you in this form. Data on this application form is restricted to the appointment panel and leadership team of the Foundation. Data such as your name will be shared with colleagues to produce name badges etc. Access requests may be shared to colleagues in operations to make suitable arrangements. Copies will be stored securely in hard and electronic format in restricted access areas of the Foundation offices / electronic storage.

Should you not be successful the information will be held by the Foundation for a maximum of one year to provide evidence for feedback and for external scrutiny of the process. Should you be successful in your application, the information provided, and further information which will be gathered at the relevant time, will be subsequently used for the administration of your employment and in relation to any legal challenge which may be made regarding our recruitment practices. If you wish to object to the processing and retention of your data in this way, please contact the Director of Operations at dataprotection@queens.ac.uk.
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