Somerville College 	CONFIDENTIAL

Equal Opportunities Monitoring Form  
Ref: E455	

Please answer the questions below by completing or ticking the appropriate box. 
Age:
	Date of Birth:
	Prefer not to say	
Sex/Gender
(this refers to your legal sex)	Male	Female	Prefer not to say	
Disability
Disability is defined as a physical or mental impairment, and the impairment has a substantial (i.e. more than minor or trivial) and long-term adverse effect on your ability to carry out normal day-to-day activities	
Do you have a disability or a long term medical condition that has lasted for at least 12 months, or is likely to last for at least 12 months, or is likely to last for the rest of your life?	Yes	No known disability	Prefer not to say	

If yes, what is your disability? (indicate below)
	Prefer not  to say	
Blind or serious impairment uncorrected by glasses		Deaf or serious hearing impairment		
Two or more impairments and/or disabling medical conditions		Long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy		
General Learning disability (such as Down’s syndrome		Mental health condition, such as depression, schizophrenia or anxiety disorder		
Social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder		Physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutches		
A disability, impairment or medical condition not listed above		A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D		

Ethnicity - this question is not about nationality, place of birth, or citizenship, it is about colour and ethnic group.	
What is your ethnicity?	
White		Other Asian background		
Gypsy or Traveller		Mixed - White and Black Caribbean		
Black or Black British - Caribbean		Mixed - White and Black African		
Black or Black British - African		Mixed - White and Asian		
Other Black background		Any other mixed background		
Asian or Asian British - Indian		Arab		
Asian or Asian British - Pakistani		Other ethnic background		
Asian or Asian British - Bangladeshi		Not known		
Chinese		Prefer not to say		
Sexual Orientation - What is your sexual orientation?	
Bisexual		Gay woman / Lesbian		
Heterosexual		Other		
Gay man		Prefer not to say		
Religion or Belief (including lack of belief) - What is your religion?	
Atheism		Judaism		
Buddhism		Sikhism		
Christianity		Spiritualism		
Hinduism		Any other religion or belief		
Islam		No religion		
Jainism		Prefer not to say		
Marriage and Civil Partnership - Are you married or in a civil partnership?	

	Yes	No	Prefer not to say	
Nationality - What is your nationality?	

	Prefer not to say	

Equal Opportunities Monitoring Information

Higher education institutions have a legal duty to collect, analyse and publish equal opportunity data about characteristics that are protected against discrimination under the Equality Act 2012, such as age, race, and disability.  Somerville is keen to comply with this legal duty so that it is able to measure the effectiveness of its equality policies, and to ensure that those who work and study at Somerville are treated equally and discrimination involving the ‘protected characteristics’ is avoided.

Therefore we need you to provide the College with your personal equal opportunities data by completing and returning this form to the Human Resources team.  Any information you provide will be presented in an anonymous format and any data that has the potential to identify you as an individual will not be published.  The information collected through this form will be held on the Human Resources database and will be accessible only by the Human Resources staff.  Data you supply will be kept strictly confidential and according to the Data Protection Act 1998.   

Code: The code used at the top of this form is a unique number and identifies the person who has completed this form only to the Human Resources Manager and Human Resources Administrator.

Somerville’s equality policy and reports can be found on www.some.ox.ac.uk/equality 

Please return one copy of this form to the Human Resources Manager 

By hard copy to:  Somerville College, Woodstock Road, Oxford. OX2 6HD 
Or by email to: human.resources@some.ox.ac.uk 

Thank you.