Application to join the Staffordshire People's Panel

Thank you for showing an interest in becoming a member of the Staffordshire People's Panel. To become a member of the Panel we first need to find out some information about you. These questions help us to ensure that we get the views and opinions of a wide cross-section of people. All responses will be treated in the strictest confidence. Please note: a) Staffordshire County Council employees or people living with employees cannot join the panel. b) Members of other residents panels such as the Staffordshire police panel or district council panels cannot join the panel. This is to ensure impartiality.

If you would like to be a member of the Staffordshire People's Panel, please answer the following questions and click submit at the end of the page.

If you have any questions please contact Wendy Bailey on 01785 854267

Please cross this box to confirm you are not an employee or living with an employee of Staffordshire County Council

Please cross this box to confirm you do not belong to any other residents panel, such as the Staffordshire police panel or your district council panel

	Please tell us your name

	Please clearly write your address and postcode in the box below

	As part of Staffordshire's commitment to tacking climate change you will be able to access questionnaires through the internet via a link sent to your email address. If you would like to receive your questionnaires via email instead of post, please clearly write your email address in the box below

	If you are happy for the Panel to contact you via telephone, please enter your home and mobile telephone numbers in the boxes below
	Home telephone number

Mobile telephone number

Are you...? (please select one only)

Male

Female

Please tell us your date of birth?

Do you have any long standing illness, disability or infirmity? (please select one only)

Yes

Q10

Does this limit your activities in any way? (please select one only)

Yes

Q11

Q12

In which of these ways does your household occupy your current accommodation? (please select one only)

Owned outright

Rent from Housing Association/Trust

Buying on a mortgage

Rent from private landlord

Rent from council

Other

Q13

How long have you lived in Staffordshire? (please select one only only)

Less than two years

6 - 10 years

Over 20 years

2 - 5 years

11 - 20 years

Q14

Are you...? (please select one only)

Single

Married

Widowed

Co-habiting

Separated/Divorced

Q15

How many children aged 17 and under are living in your household? (please select one only)

None

3 or more

Q16

How many adults aged 18 or over, including yourself, are living in your household? (please select one only)

5 or more

Q17

Q18

If you are currently employed, do you work in Staffordshire? (please select one only)

Yes

Q19

If you are currently employed, how do you normally get to work? (please select one only)

Car driver

Train

Walk

Car passenger

Bicycle

Motorcycle/scooter

Bus

Taxi

Other

Q20

Do you care for, or help to care for, a relative or friend with a long-term limiting illness or disability, including problems linked with old age? (please select one only)

Yes

Q21

Do you personally use the internet at home? (please select one only)

Yes

Q22

Which of the following Staffordshire People's Panel consultation activities would you like to have the opportunity to get involved with? (please select all that apply)

Focus groups (a group of residents come together to discuss council services)

Individual interviews (a one-to-one session to discuss council services)

Telephone interviews (a one-to-one telephone call to discuss council services)

Mystery shopping (posing as normal customers to test out council services)

THANK YOU FOR COMPLETING THESE QUESTIONS - ALL RESPONSES ARE TREATED IN CONFIDENCE.

http://www.snapsurveys.com/

Application to join the Staffordshire People's Panel

If you would like to be a member of the Staffordshire People's Panel, please answer the following questions and click submit at the end of the page.If you have any questions please contact Wendy Bailey on 01785 854267

THANK YOU FOR COMPLETING THESE QUESTIONS - ALL RESPONSES ARE TREATED IN CONFIDENCE.

If you would like to be a member of the Staffordshire People's Panel, please answer the following questions and click submit at the end of the page.

If you have any questions please contact Wendy Bailey on 01785 854267