Ref N2215: The Mid Yorkshire Hospitals NHS Trust 

MONITORING AND OTHER INFORMATION

Please mark your preference in each of the categories below.

Candidate details

Title			Name					Postcode

Address

Principal Residence
Which region does your principal residence fall within?

North East				East			Wales
North West				London		Scotland
Yorkshire & Humber		South East		Northern Ireland
East Midlands			South West		I prefer not to say
West Midlands

Special category monitoring information 

We respect your privacy and are committed to protecting your personal data.  These special categories of personal data will not be shared with third parties, unless expressly stated. It is important that you read this information together with our privacy notice so that you are fully aware of how we use your data.  

Date of birth

I prefer not to say

Gender

Male			Female		I prefer not to say

I self-identify as:

Disability 
Many people do not consider themselves to be disabled, but under the Disability Discrimination Act you can consider yourself disabled if you have a physical or mental impairment or long term health condition, and  the effects are expected to last, or have lasted for a year or longer, or your day to day activities would be limited without medication, treatment or adjustments (for example the use of inhalers, physiotherapy, a hearing or visual aid or insulin).  Taking this into account, do you consider yourself disabled? 

No		Yes, a lot		Yes, a little		I prefer not to say

If yes, how would you describe your disability?

More information on disability can be found on the Public Appointments website.

Ethnic Origin
Please mark the option that most accurately describes your ethnicity:

White		English / Welsh / Scottish / Northern Irish / British
		Irish
		Gypsy or Irish Traveller
		Any other white background, please describe

Black African / Caribbean / British
African
		Caribbean
		Any other Black / African / Caribbean background, please describe

Asian		Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background, please describe

Mixed / Multiple Ethnic Groups
				White & Black Caribbean
				White & Black African
				White & Asian
				Any other Mixed / Multiple ethnic background, please describe

Other Ethnic Group
				Arab
				Other Ethnic group, please describe
	
I prefer not to say
Religion or beliefs 
How would you describe your religion or beliefs?

Buddhist		Christian		Hindu		Jewish		Muslim

Sikh			No religion or Athiest		Other

I prefer not to say

Sexual orientation 
How would you describe your sexual orientation?

Bisexual		Gay or Lesbian		Heterosexual

Other

I prefer not to say

Do you hold any other public appointments? 

This includes all non-departmental public bodies (NDPBs), NHS bodies, parole boards and research councils. It does not include sitting as a school governor, being a magistrate or any positions within charities.

No		1		2		3		4		5/9

10 or more

I prefer not to say

The information in the following sections will be shared with the panel.

Your principal employment
Please describe your main employment and tick the occupational sector that best describes your background (for regulated activities - please also provide your professional registration number)

Mostly private sector		Mostly civil service 		Mostly wider public sector

Mostly third sector		Mixed				

Other (eg Retired or Student)

I prefer not to say

Significant Political Activity 
Have you undertaken any significant political activity for a political party in the last five years?

Significant political activity is defined as being employed by a political party, holding significant office in a party, standing as a candidate for a party in an election, having publicly spoken on behalf of a political party or having made significant donations or loans to a party. Significant loans and donations are those of a size which are reported to the Electoral Commission, in line with a central party’s reporting threshold.

No				Yes		If yes, please indicate the parties

Conservative		Labour		Liberal Democrats		Independent

Other party (please specify)

Other information 

Declaration of interests and ensuring public confidence 
Do you have any business or personal interests that might be relevant to the work of the body for which you have applied and which could lead to a real or perceived conflict of interests were you to be appointed? 

				No		Yes

NHS Improvement has a duty to ensure that those we appoint to NHS boards are of good character, have not been associated with any serious misconduct or mismanagement relating to any current or past office or employment, and will ensure an open and honest culture across all levels of the organisation.  Is there anything in either your professional or personal history which may affect your suitability for appointment to this post or may cause embarrassment or bring the organisation into disrepute, were you to be appointed?

				No		Yes

If you answered yes to either question, please give details below. This information will be shared with the selection panel and should you be invited to interview, the selection panel will explore this in the context of performing the role for which you are applying.  Failures to disclose such information could result in an appointment being terminated. 

Please tell us how you found out about this post: 

Thank you for taking the time to complete this form

This diversity information is collected by government departments managing appointments to the board of public bodies, on behalf of the Cabinet Office and The Office of the Commissioner for Public Appointments (OCPA). This data will not be connected to your name when it is shared, it is supplied anonymously.  It is collected for the purposes of measures or decisions with respect to your application for a government public appointment.

OCPA collects diversity information in order to produce management information about the public appointments process, and the diversity of the field of applicants. It will be published on OCPA’s website, in summary form, in order to enable government to meet its public sector equality duty under section 149 of the Equality Act 2010 and section 75 of the Northern Ireland Act 1998.

This data is collected and held on the basis that you consented to provide this information to departments alongside your application and you have not given notice that you do not wish for your data to be processed for this purpose.

This data may be held for up to 5 years by OCPA, Cabinet Office and the Government Department, who are the co-controllers of the data. This data shared with Cabinet Office IT suppliers, identified as processors, in order to securely collect and store the data.