Childrens Centre Consultation
Feedback Form      

Before completing this feedback form we advise you to read the consultation materials provided.  To view this document and for more information you can visit ww.staffordshire.gov.uk/childrenscentreconsultation.  Please note your views must be submitted to us by 5pm on Sunday 11th March, 2012. If you would like the survey in another language or format e.g. large text, please contact 0300 111 8000 or email: childrenscentreconsultation@staffordshire.gov.uk.  If you are returning a paper copy of this survey please return to: Childrens Centre Consultation, Early Years and Childcare Service, Wedgwood Building, Tipping Street, Stafford, ST16 2DH. All survey responses will be treated confidentially

1.	Have you ever received any of the following support from a Childrens Centre(s) in Staffordshire?
	Yes - Childcare		Yes - Support with my own or child's disability or special needs		No
	Yes - Parenting support		Yes - Information and advice		Other

	Other (please specify)

2.	What do you think of the proposed changes to Children Centres in Staffordshire?

3.	How do you think these proposals may impact on you and/ or your family?

4.	How do you think these proposals may impact on your organisation, the parents and children you support, and the service that you might provide to them?

5.	Is there anything else you would like us to think about as part of the development of Children Centres in Staffordshire?

6.	Please let us know other comments you have on our proposals?

Tell us about yourself

To help us understand views on proposals we would value the following optional details.  You do not have to complete this section, but it would be very helpful if you did as the information will help us to understand the impact that the proposed changes will have on communities.

7.	Which group best describes you?  (please tick all that apply)
	User of a Childrens Centre for day care		Employee of Staffordshire County Council
	User of a Childrens Centre for other activities		Commissioned Early Years Service Provider i.e. funded by the Council
	Resident (individual)		Other local Early Years Service Provider, ie. not funded by the Council
	Parents Group		Elected councillor/ MP
	Community Group		Other
	School

Other (please specify)

8.	How many people live in your household?
	- Number of adults (aged 16+)
	- Number of children (aged 0-4)
	- Number of children (aged 5-16

9.	Are you?
	Male		Female

10.	Your age - are you:
	Under 16 years		19-24 years		35-44 years		55-64 years
	16-18 years		25-34 years		45-54 years		65+ years

11.	I would describe my ethnic origin as:
	White-British		Mixed Heritage		Asian & Asian British		Other
	White-Other		Black or Black British		Chinese

Other Ethnic group, please state:

12.	Do you consider yourself to have a disability?
	Yes		No

13.	If you consider yourself to be disabled, please specify:
	Communication		Hearing		Learning		Mental Health
	Mobility		Physical		Visual		Other

Other, please give further details if you wish:

Please add your personal details (information provided here will not be published).

14.	Name:

15.	Organisation (If applicable)

16.	Address:

17.	Postcode:

18.	Date:

Thank you for completing the feedback form.

Please click the 'submit' button to send your survey to us.   If you are returning a paper copy please send to: Childrens Centre Consultation, Early Years and Childcare Service, Wedgwood Building, Tipping Street, Stafford, ST16 2DH.