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District of Easington

Community Advisory Panel Recruitment Questionnaire

Being a member of District of Easington’s Community Advisory Panel gives local people a chance to share their views about the council’s activities, issues affecting their daily lives and the neighbourhoods they live in. Members have the opportunity to influence local decisions and to help shape and improve council services.

Anyone over the age of 16 can be a member but we need to make sure that the panel is fully representative of the population of the district. To help us do this we ask new members to fill in this questionnaire. It is important that the person who completes the questionnaire is also the person who will complete future surveys.
If you have any queries or concerns about this questionnaire, please do not hesitate to contact NWA Social Research on free-phone 0800 316 3630.

TOPICS OF INTEREST
Q1
  Listed below are a number of topics. Please tick any that interest you and on which you may wish to be consulted in the future. (Please tick as many boxes as apply)
 
 
 
 
 
 
 
 
 
   
 
 
   
 
Q2
  In the future, the Panel will use a variety of methods of consultation. Please could you tell use which of these methods you would be interested in taking part in. (Please tick as many as apply)
 
 
 
 
 
 
 
   
Q3
  By what method can we contact you? (Please tick all that apply)
 
 
 
 
 
 

ABOUT YOU

To ensure that we are recruiting a representative sample of people, please could we take some details about yourself? Your personal information will be treated in confidence and in accordance with data protection legislation.
Q4
  Are you...?
 
 
Q5
  To which age group do you belong? (Please tick one box only)
 
 
 
 
 
 
 
Q6
  Do you consider yourself to have a disability? (This may include any long-standing illness, disability or infirmity which effects your daily living) Long-standing means that it has lasted, or is likely to last, for over a year.
 
 
Q7
  IF YES; Please tick the relevant boxes below
 
 
 
 
 
 
 
 
 
Q8
 
Q9
  To which of these groups do you consider you belong? (Please tick one box only)
 
 
 
 
 
 
 
 
Q10
  What languages do you usually use at home and/or work? (Please type the languages below and tick all the boxes that apply)
   
 
 
 
 
   
 
 
 
Q11
  What is your religion or belief? (Please tick one box only)
 
 
 
 
 
 
Q12
  How do you describe your sexuality? (Please tick one box only)
 
 
 
 
 
Q13
  Finally, please could you tell us your name and address?
 
 
 
 
 
 

Thank you for expressing an interest in joining the District of Easington Community Advisory Panel. A member of staff from NWA Research will be in contact in the near future.  

DATA PROTECTION STATEMENT
By completing this questionnaire you give the District of Easington the authority to collect and retain information about you.  The information collected about you will be held securely and will be processed to produce statistical reports.  No personal data will be disclosed.  In order to run the Community Advisory Panel, the Council has entered into a contract with NWA Research, and will share the information with that organisation.  For the purposes of provision of this service, NWA acts as a department of the Council and is bound by the contract to treat your information confidentially. The District of Easington is the Data Controller for the purposes of the Data Protection Act.
  Please tick the box below, to confirm that you have read and agree to your information being held by the District of Easington/NWA Research in accordance with the Data Protection Statement as given above.