EQUALITY & DIVERSITY MONITORING FORM (HR-F029) Subscribe EQUALITY & DIVERSITY MONITORING FORM Equality, Diversity & Inclusion (EDI) Monitoring Form (HR-F029)SECTION 1: PERSONAL DETAILSTitle- Select -MrMrsMissMsMxOtherStaff Member NameStaff_IDJob TitleCare Worker / Support WorkerComplex Care WorkerSenior Care Worker / MentorField SupervisorCare Coordinator / Rota SchedulerClinical LeadQuality Assurance / Compliance OfficerHR / Recruitment AdministratorImplementation ResearcherDeputy Care ManagerRegistered Care ManagerOperating Local Authority- Select -HaringeyIslingtonBarnetWaltham ForestCamdenHackneyBrentHarrowRedbridgeNewhamCity of LondonWestminsterTower HamletsBarking and DagenhamHaveringKensington and ChelseaHammersmith and FulhamEalingHillingdonHounslowSouthwarkLambethLewishamGreenwichWandsworthRichmond upon ThamesMertonKingston upon ThamesSuttonBexleyBromleyCroydonOtherSECTION 2: AGE , SEX, GENDER IDENTITY & HEALTHAge Band- Select -16-1718-2425-3435-4445-5455-6465+Prefer not to sayEthnic Group- Select -White: English / Welsh / Scottish / Northern Irish / BritishWhite: IrishWhite: Any other White backgroundMixed / Multiple ethnic groupsAsian / Asian British: IndianAsian / Asian British: PakistaniAsian / Asian British: BangladeshiAsian / Asian British: ChineseBlack / African / Caribbean / Black BritishOther ethnic groupPrefer not to sayWhat is your sex as registered at birth- Select -FemaleMaleIntersexOtherPrefer not to sayReligion or Belief- Select -No religionChristian (all denominations)BuddhistHinduJewishMuslimSikhAny other religionPrefer not to sayWhich of the following best describes your gender identity- Select -WomanManNon-binaryAgenderGender fluidI prefer to self-describePrefer not to sayWhich of the following best describes your sexual orientation- Select -Heterosexual / StraightGay / LesbianBisexualPansexualAsexualQueerI prefer to self-describePrefer not to sayDo you consider yourself to have a disability, long-term illness, or health condition- Select -YesNoN/APlease select the category or categories that best apply to you- Select -Physical impairment or mobility issueSensory impairment (e.g., visual or hearing)Mental health condition (e.g., depression, anxiety, schizophrenia)Neurodivergent condition (e.g., Autism, ADHD, Dyslexia, Dyspraxia)Learning disabilityLong-term medical condition (e.g., diabetes, epilepsy, asthma)I prefer to self-describePrefer not to saySECTION 3: SOCIAL MOBILITY, RESPONSIBILITIES & COVENANTDo you have unpaid caring responsibilities for a family member, partner, or friend- Select -NonePrimary carer of a child/children (under 18)Primary carer of disabled child/childrenPrimary carer of disabled adult (18 and over)Primary carer of older personSecondary carer (another person carries out the main caring role)Prefer not to sayThinking back to when you were aged about 14, which best describes the sort of work the main/highest income earner in your household did in their main job- Select -Modern professional occupations (e.g., teacher, nurse, engineer, software developer)Clerical and intermediate occupations (e.g., secretary, call centre worker, nursery nurse)Senior managers and administrators (e.g., finance manager, chief executive)Technical and craft occupations (e.g., mechanic, plumber, electrician)Semi-routine manual and service occupations (e.g., postal worker, security guard, receptionist)Routine manual and service occupations (e.g., cleaner, waiter, care worker, driver)Long-term unemployed (claimed Jobseeker’s Allowance or earlier unemployment benefit for more than a year)Not applicable / I don't knowPrefer not to sayAre you a member of the Armed Forces Community?- Select -YesNoPrefer not to sayDo you have any work restrictions?- Select -Veteran / Service LeaverServing Member of the Regular or Reserve ForcesImmediate Family Member / Partner of serving personnel or veteranPrefer not to saySECTION 4: DECLARATIONDigital Signature (Type Full Name)Date SignedNext Review Date: I confirm all information is accurate; false claims will result in dismissal. I consent to Mutima Care processing my data.SUBMIT FORM
