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MONITORING FORM

Public appointments are made on merit in accordance with the Cabinet Office Code of Governance and the Public Appointments Order in Council. By completing the attached diversity monitoring form you will be helping us meet our public sector equality duty under section 149 of the Equality Act 2012.

Publication of monitoring information

The Department of Health announces details of all public appointments on gov.uk and we are required to include information on your political activity. In addition we are required to provide anonymised information to the Commissioner for Public Appointments and may also be asked to provide anonymised information – in summary form only, in response to Parliamentary Questions and other public enquiries.

In line with Government policy, and in accordance with the provisions of the Data Protection Act, the information you provide will be held confidentially and can only be used if you provide us with your consent. The Data Protection Act requires that those providing this information must be informed and their consent given, even though individuals are not identified.

Diversity monitoring information is not used at any stage in the assessment and selection process. It will not be seen by the panel assessing your application.

Ministers publicise the appointments they make and in doing so, provide information on whether appointees have been politically active in the past five years and if so, in what way. Political activity information is primarily for monitoring purposes only, however if you are shortlisted for interview, this information will be shared with the selection panel. The reason for this is that it is appreciated that such activities may have given you relevant skills, including experience gained from committee work, collective decision-making, resolving conflict and public speaking. If you have had such experience and you consider it relevant to your application for this post, you should also take the opportunity to include it separately in your supporting statement. If possible, you should not, however, identify the relevant political party in your statement.

Public Appointments: events and vacanciesPeriodically, Cabinet Office arranges events to which applicants for public appointments may be invited. Cabinet Office and other government departments may also ask the Department of Health for names and contact details of candidates that might have suitable skills to apply for other appointments.

 ConsentPlease tick the relevant box to show whether you give your consent or not for your name and contact details to be shared for these purposes.

I provide my consent ☐I do not provide my consent ☐

Your responses to sections 1 – 8 will never be made available to the panel considering your application. Please tick one box only for questions 1 – 6.

1. Gender

What is your gender?

[ ] female [ ] male[ ] I prefer to describe myself as _________________________________[ ] I prefer not to say

2. Disability

Many people do not consider themselves to be disabled, but under the Equality Act 2010 you can consider yourself disabled if you have a physical or mental impairment and the impairment has a substantial and long term adverse effect on your ability to carry out normal day to day activities.

Do you consider yourself disabled?

[ ] no[ ] yes If yes, how would you describe your disability? ___________________________[ ] I prefer not to say

If you are disabled and in receipt of benefits you need to be aware that under current regulations, if you are remunerated for an appointment it may affect your entitlement.

The Department of Health operates a Guaranteed Interview Scheme (GIS) for disabled people. If you wish to apply for consideration under the scheme please complete the GIS form and send it with your application.

3. Ethnicity

Please mark the box that most accurately describes your ethnicity:

Asian Black[ ] Bangladeshi [ ] African[ ] Chinese [ ] Caribbean[ ] Indian [ ] Other Black origin[ ] Pakistani [ ] Other Asian origin

Mixed Ethnic White[ ] Of more than one ethnicity [ ] British, Irish or other White Background[ ] I prefer not to say

4. Age

Please tick the age band you fall into:

[ ] 18-25 [ ] 26-35 [ ] 36-45 [ ] 46-55 [ ] 56-65 [ ] 66 or older[ ] I prefer not to say

5. Sexual Orientation

What is your sexual orientation?

[ ] bisexual [ ] gay man [ ] heterosexual [ ] lesbian [ ] other[ ] I prefer not to say

6. Religion or belief

What is your religion or belief?

[ ] Buddhist [ ] Christian [ ] Hindu [ ] Jewish [ ] Muslim [ ] Sikh[ ] Other [ ] No Religion or Atheist [ ] I prefer not to say

7. What is your principal place of residence?

Please enter the County or City that you live in along with the first part of your postcode e.g. Dyfed SY23; London SE18

County/City_____________________ Post Code [ ] [ ] [ ] [ ]

8. What is your principal employment, if any?

Please describe your main employment and tick the occupational sector box that best describes you:

Employment __________________________________________

[ ] Mostly Civil Service [ ] Mostly Private Sector [ ] Mostly Third Sector [ ] Mostly wider Public Sector [ ] Mixed [ ] I prefer not to say

Only the information provided in section 9 (Political Activity) below will be made available to the panel if you are called for interview.

9. Political Activity

Have you undertaken any political activity for a political party in the past five years?

[ ] No[ ] If yes, please indicate the activity undertaken and for which party/parties: [ ] held office [ ] public speaking [ ] stood for election [ ] made donations to a party (if so, please say how much _______________)[ ] any other political activity (if so, please specify ______________________)

Party/Parties___________________________________________________

10. Recruitment

To help us target our recruitment activity effectively and publicise posts in the future, it would be helpful if you could let us know how you initially found out about the vacancy:

[ ] Cabinet Office website[ ] Arm’s Length Body/or Committee website[ ] Newspaper/Journal (hard copy)[ ] Newspaper/Journal (online)[ ] DH Appointments Twitter account[ ] Networks or Word of Mouth[ ] Other (including other website, Social Media), please state: ______________________

11. Conflicts of interest

If you have any business or personal interests that might be relevant to the work of the ALB/Committee and which could lead to a real or perceived conflict of interest were you to be appointed, please provide brief details below as well as in your supporting letter.

Do you consider yourself to have a real or perceived conflict of interest?

[ ] no[ ] yes If yes, please provide brief details: _____________________________________

________________________________________________________________________

12. Personal Conduct

If there is anything relevant to your suitability as a public appointee – for example any convictions or bankruptcy, please provide brief details below:

[ ] no[ ] yes If yes, please provide brief details: _____________________________________

________________________________________________________________________

Declaration

I declare that the information supplied in my application, including that referring to conflicts of interest and previous conduct, is complete and correct to the best of my knowledge. I have also read the information pack and can confirm that I am eligible to be considered for appointment to this body. I also certify that I will immediately inform the Department of Health of any changes in circumstances that affect the answers I have given.

Candidate’s Name:

Date: