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, this helps us to ensure that the panel reflects the different types of people living in the area.   If we have a place available for you we will add you to our panel membership and send you your first questionnaire.  If there is no position on the Panel for you right now, we will keep your details and contact you if a place arises.   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 our Consultation and Market Research Adviser 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

Thank you for taking the time to complete this questionnaire.   Please now press "submit" to return your completed questionnaire.