Royal College of Midwives Equality and Diversity Monitoring Form

The Royal College of Midwives (RCM) is committed to equal opportunities and reflecting the diversity of our membership. We strive to ensure that all members are treated in a fair and equal manner regardless of their gender; race; disability; sexual orientation; age; being pregnant or having a child; and religion or belief.

To ensure effective implementation of our equality and diversity policy it is necessary to collect information on a number of characteristics relating to equality and diversity through the use of diversity monitoring. We would therefore ask that you complete this form.

Please be assured that forms are anonymous.

1. Please indicate your sex/gender

☐ Female☐ Male

☐ Prefer not to say

2. Please indicate your age band

☐ Under 21☐ 21-30☐ 31-40☐ 41-50

☐ 51-60☐ 61-65☐ Over 65☐ Prefer not to say

3. Please indicate your ethnic group (options are listed alphabetically)

☐ Arabic or Arabic British☐ Asian or Asian British - Bangladeshi☐ Asian or Asian British - Chinese☐ Asian or Asian British - Pakistani☐ Asian or Asian British - Other☐ Black or Black British - African☐ Black or Black British - Caribbean☐ Black or Black British - Other☐ Mixed - White and Asian

☐ Mixed - White and Black African☐ Mixed - White Black Caribbean☐ Mixed - Other☐ White - British☐ White - Gypsy or Irish Traveller☐ White - Irish☐ White - Other☐ Other Ethnic Group☐ Prefer not to say

4. Do you consider yourself to have a disability, impairment, health condition, a learning difference or learning disability?

(Disability is legally defined as a ‘physical or mental impairment which has substantial and long term adverse effect on a person’s ability to carry out normal day-to-day activities).

☐ Yes☐ No

☐ Prefer not to say

Please indicate your disability, difference, impairment or health condition from the options below:☐ Learning difference such as dyslexia☐ Learning disability or cognitive impairment such as autism or a head-injury☐ Long-standing illness or health condition such as cancer, HIV, diabetes, or epilepsy☐ Mental health condition, such as depression or schizophrenia☐ Physical impairment or a condition that affects your mobility such as an impairment that requires you to use a wheelchair or affects arm movement☐ Sensory impairment, such as being blind/having a serious visual impairment or being deaf/having a serious hearing impairment☐ Other

5. Please indicate your religion or belief (options are listed alphabetically)

☐ Atheist☐ Buddhist☐ Christian☐ Hindu☐ Jewish

☐ Muslim☐ No religion☐ Sikh☐ Other☐ Prefer not to say

6. Please indicate your sexual orientation (options are listed alphabetically)

☐ Bisexual☐ Gay Man☐ Gay Woman/Lesbian

☐ Heterosexual☐ Other☐ Prefer not to say

7. Is your gender identity the same as assigned at birth?

☐ Yes☐ No

☐ Prefer not to say

8. Are you currently pregnant or have been so in the last 12 months?

☐ Yes☐ No

☐ Prefer not to say

Thank you for taking the time to complete this form.