EBS Counselling Service is committed to equality of opportunity and to the avoidance of unlawful discrimination. In pursuit of this, it is essential that no person experiences more or less favourable treatment on the grounds of disability, gender, sexual orientation, marital status, family responsibility, age, race, colour, ethnic origin, nationality, political or religious beliefs.
The Disability Discrimination Act 1995 protects employees, job applicants, volunteers and the public who fall within the definition of disability. Under this legislation, the Act defines disability to include those who currently have a disability and those who have had a disability in the past. This can include physical or mental impairment, which has a substantial and long-term adverse effect on a person’s ability to carry out normal day to day activities. Long term is taken to mean lasting for a period greater than twelve months.
This form has been designed in conjunction with the ethos of EBS and the Disability Discrimination Act 1995. It is necessary for monitoring the effectiveness of the policy and our recruitment procedures and for consideration to be given to any specific support you may require because of a disability.
Please return this form, together with your application form.
1. How did you hear about the placement/training opportunity?
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2. Gender
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3. Date of birth
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4. Marital status
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5. Ethnic Origin
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6. Nationality ……………………………………………………………………….
7. Do you consider yourself to have a disability? Yes/No
If you have answered yes, please give further details which will help EBS to provide adequate support for your particular needs.
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8. Under the definition within the Discrimination Act 1995, what type of disability do/did you have?
Blind/partially sighted Yes/No Other mobility problem Yes/No
Deaf/hard of hearing Yes/No Dyslexia Yes/No
Wheelchair user Yes/No Mental health problems Yes/No
Unseen disability (e.g. asthma, diabetes, epilepsy)
Please specify …………………………………………
9. Do you need any equipment or support because of your disability in order to carry out the role for this post or for an interview? If yes please specify.
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10. Do you need any special consideration for access? If yes please specify……………………………………………………………………
11. Surname ……………………………………………………………..
Forename ……………………………………………………………..
Signature ……………………………………………………………..
Date ………………………………………………………………
