Havant's Citizens' Panel Recruitment Questionnaire If you would like to join Havant's Citizens' Panel please provide your contact information on this questionnaire and complete the details about you so that we can make sure that the panel reflects the different types of people living in the area. If this information is difficult to read we can provide it in another format, for example in large print or in another language.  If you have any queries or would like help to complete this questionnaire please contact Beth Manwaring on 023 9244 6629 or consultation@havant.gov.uk   ALL OF THE INFORMATION YOU GIVE US WILL BE KEPT CONFIDENTIAL AND NOTHING WILL BE PUBLISHED WHICH ALLOWS ANY INDIVIDUAL TO BE IDENTIFIED.   Q1 Contact information   Title e.g. Mr, Mrs, Miss   First name   Surname   Address   Postcode   Telephone No (home).   Telephone No (mobile)   Email address Q2 Are you...   Male   Female   Q3 Please tell us in which year you were born...   Q4 Do you consider yourself to have a disability?   Yes   No   Q5 If yes, how does your disability affect you?  Please tick all that apply   Affects hearing   Affects mobility Affects vision Other Q6 If there are dependent children living in your household please indicate their ages Please tick all that apply   Under 5   5 - 8 9 - 11 12 - 16 17 - 18 Q7 How would you describe your ethnic origin?   White - British   White - Irish White - Other White Background (please state below) Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Any Other Mixed Background (please state below) Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Other Asian Background (please state below) Black or Black British - Caribbean Black or Black British - African Black or Black British - Other Black Background (please state below) Chinese Other   Other, please state   Q8 What is your current employment status?   Employed full-time (30 or more hours a week)   Employed part-time (less than 30 hours a week) Looking after home/family Retired Self employed Unemployed and seeking work Unable to work due to long term sickness/disability Student/full time education Government apprenticeship or training scheme Other   Other, please specify Q9 Do you...   Own your own house (with or without a mortgage)   Rent from a private landlord Rent from Portsmouth City Council Rent from a housing association Live with family Other   Other, please state Q10 How long have you lived in the Borough of Havant?   Less than 1 year   1 - 2 years 3 - 5 years 6 - 10 years 11 + years Q11 In which of the following ways would you be willing for us to contact you?   Paper questionnaires sent by post   Electronic questionnaires sent by email Being interviewed by someone face to face Informal group discussions Being interviewed over the telephone at a pre-arranged time Q12 Please tell us if there are any particular topics you are interested in   Education, parenting and childcare   The local environment and environmental issues Arts, leisure and culture Transport and travel Crime and disorder Young people Planning, buildings/the 'built environment' Services for older people Consumer issues Business issues   Other, please state Q13 Do you know which ward you live in?   Barncroft   Hayling West   Bondfield   Stakes Bedhampton   Cowplain Battins   Purbrook Emsworth   Warren Park St Faiths   Hart Plain Hayling East   Waterloo