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Diversity Monitoring Form 2018 Name: All information provided will be viewed only by the HR team for the purpose of monitoring the diversity profile of Wales Co-operative Centre staff and informing diversity initiatives. Data will be treated in line with the principles of the Data Protection Act. Where possible, questions have been based on Census questions and guidance from the Equality and Human Rights Commission. All questions provide staff with the opportunity to answer “Prefer not to disclose” and members of staff should feel confident in their ability to select this option without fear of reprisal. With which gender do you identify? FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX Prefer not to discloseDo you intend to, are you currently undergoing, or have you undertaken a process of gender reassignment? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Prefer not to disclose What is your sexual orientation? FORMCHECKBOX Bisexual FORMCHECKBOX Gay FORMCHECKBOX Lesbian FORMCHECKBOX Heterosexual FORMCHECKBOX Prefer not to disclose What is your legal marital or same-sex civil partnership status? Please tick. FORMCHECKBOX Single FORMCHECKBOX Living with a partner FORMCHECKBOX Married FORMCHECKBOX In a registered same-sex civil partnership FORMCHECKBOX Separated, but still legally married FORMCHECKBOX Separated, but still legally in a same-sex civil partnership FORMCHECKBOX Divorced FORMCHECKBOX Formerly in a same-sex civil partnership which is now legally dissolved FORMCHECKBOX Widowed FORMCHECKBOX Surviving partner from a same-sex civil partnership FORMCHECKBOX Prefer not to discloseDo you consider yourself to be disabled? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Prefer not to disclose Do you have an impairment that is physical and/or mental, which has substantial, long term adverse effects on your ability to carry out normal day to day activities? FORMCHECKBOX Yes (please specify) FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Prefer not to disclose If yes, please select from the list (tick as many as apply) FORMCHECKBOX Mobility issues FORMCHECKBOX Hearing impairment FORMCHECKBOX Visual impairment FORMCHECKBOX Physical impairment FORMCHECKBOX Learning difficulty FORMCHECKBOX Living with a long term condition FORMCHECKBOX Mental health issue FORMCHECKBOX Prefer not to discloseIf other please specify: FORMTEXT ?????Do you look after, help or support family members, friends, neighbours or others, in an unpaid capacity, because of either problems related to old age or long-term physical or mental ill health / disability? FORMCHECKBOX No FORMCHECKBOX Yes, 1 – 19 hours per week FORMCHECKBOX Yes, 20 - 49 hours per week FORMCHECKBOX Yes, 50 or more hours per week FORMCHECKBOX Prefer not to disclose What is your country of birth? FORMCHECKBOX England FORMCHECKBOX Northern Ireland FORMCHECKBOX Republic of Ireland FORMCHECKBOX Scotland FORMCHECKBOX Wales FORMCHECKBOX Other (please specify) FORMTEXT ????? FORMCHECKBOX Prefer not to discloseWhat is your national identity? FORMCHECKBOX British FORMCHECKBOX English FORMCHECKBOX Irish FORMCHECKBOX Northern Irish FORMCHECKBOX Scottish FORMCHECKBOX Welsh FORMCHECKBOX Other (please specify) FORMTEXT ????? FORMCHECKBOX Prefer not to discloseWhat is your ethnic group? FORMCHECKBOX Arabic FORMCHECKBOX Asian / British Asian FORMCHECKBOX Black / African / Caribbean / Black British FORMCHECKBOX White FORMCHECKBOX Other ethnic group (please specify) FORMTEXT ?????What is your religion and/or belief? FORMCHECKBOX Atheist FORMCHECKBOX Buddhist FORMCHECKBOX Christian (all denominations) FORMCHECKBOX Hindu FORMCHECKBOX Jewish FORMCHECKBOX Muslim FORMCHECKBOX Sikh FORMCHECKBOX Other religion and/or belief (please specify) FORMTEXT ?????What is your main language? FORMCHECKBOX British Sign Language FORMCHECKBOX English FORMCHECKBOX Welsh FORMCHECKBOX Other (please specify) FORMTEXT ????? FORMCHECKBOX Prefer not to disclose We would like to determine your language skills in accordance with our Welsh Language Scheme. Using the Welsh Language Descriptors below, please tick the relevant box to indicate your current level of Welsh.012345Listening FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Reading FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Speaking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Writing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Prefer not to disclose FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Are you level 5 in any other languages? FORMCHECKBOX Yes (please specify) FORMTEXT ????? FORMCHECKBOX No FORMCHECKBOX Prefer not to disclose Welsh Language DescriptorsListeningReadingSpeakingWritingLevel 5Able to understand all conversations involving workAble to understand all material involving workFluent – able to conduct a conversation and answer questions, for an extended period of time where necessarySkilled – able to complete complex written work without the need for revisionLevel 4Able to follow the majority of conversations involving work including group discussionsAble to read the majority of material in own areaAble to speak the language in the majority of situations using some English wordsAble to prepare the majority of written material related to the area, with some assistance in terms of revisionLevel 3Able to follow routine conversations involving work between fluent Welsh speakersAble to read routine material with a dictionaryAble to converse with someone else, with some hesitancy, regarding routine work issuesAble to draft routine text, with editing assistanceLevel 2Able to understand a basic social conversation in WelshAble to read basic material involving work (slowly)Able to answer simple enquiries involving workAble to answer simple correspondence with assistanceLevel 1Able to understand basic enquiries in Welsh (e.g. “Ble mae…?”; “Ga i siarad ?…?”)Able to read basic words and phrases e.g. signs or short and simple notesAble to conduct a general conversation (greetings, names, sayings, place names)Able to write basic messages (“Diolch am y llythyr”; “Dyma gopi o’r map”)Level 0No Welsh language skills at allNo Welsh language skills at allNo Welsh language skills at allNo Welsh language skills at all ................
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