Thank you for agreeing to become a member of the Dacorum Citizens’ Panel. All individual responses are private and confidential: NWA is registered under the Data Protection Act. Please answer the questions by ticking the appropriate boxes, or by writing comments in the space provided.

About yourself

Q1

	Are you:
		Male		Female

Q2

Which of the following age groups do you belong to?

18 to 24

25 to 39

40 to 49

50 to 59

60 to 64

65 years and over

Q3

	Which of these activities best describes what you are doing at present? (Please only tick one box - only tick 'looking after the home' if this is your main activity and none of the other options apply)
		Employee in full-time job (30 hours plus)		Unemployed & available for work
		Employee in part-time job (under 30 hours)		Permanently sick/ disabled
		Self employed full or part time		Wholly retired from work
		On a government supported training programme (e.g. Modern Apprenticeships)		Looking after the home
		Full-time education (school/ college/ university)		Doing something else (please write below)

Q4

	What is your occupation (or, if retired or not working, what was your previous occupation)? (Please write in)

Q5

	Are you an employee or Councillor of Dacorum Borough Council?
		Employee		Councillor
		Neither of these

Q6a

	Do you have any long-standing illness, disability or infirmity? (Long standing means anything that has troubled you over a  period of time or that is likely to affect you over a period of time.)
		Yes		No

Q6b

	Does this illness or disability limit your activities in any way?
		Yes		No

Q7

	Are you a Registered Carer?
		Yes		No

Q8

	To which of these groups do you consider you belong? (tick one box only)
		White - British		Asian or Asian British - Indian
		White - Irish		Asian or Asian British - Pakistani
		Other White background (please write in below)		Asian or Asian British - Bangladeshi
		Mixed - White & Black Caribbean		Any other Asian background (please write in below)
		Mixed - White & Black African		Black or Black British - Caribbean
		Mixed - White & Asian		Black or Black British - African
		Any other mixed background (please write in below)		Any other Black background (please write in below)
		Chinese		Any other ethnic group (please write in below)

Q9

	Your home. Is this - (Please tick one box)
		Privately owned or mortgaged		Rented from a private landlord
		Rented from the Council		Lodge with family
		Rented from a Housing Association		Other (please write in below)

Q10

	How many people live in your household (including yourself)? (Please write number in each box below)
	CHILDREN UNDER 5
	CHILDREN 5 - 11
	YOUTHS 12 - 17
	ADULTS 18 - 64
	ADULTS 65 & over

Q11

	Does your household have access to a car or van? (Please tick one box)
		Yes - 1 car/van		Yes - 2+ cars/vans		No

Dacorum Card

The Dacorum Card is a local discount card available to all Dacorum residents who receive means-tested benefits.

Q12a

	Do you have a 'Dacorum Card'? (Please tick one box)
		Yes		No

Q12b

	IF YOU DO NOT HAVE A DACORUM CARD - Were you aware of the Dacorum Card?
		Yes		No

Q12c

	IF YOU DO NOT HAVE A DACORUM CARD - Do you receive means-tested benefits? (e.g. Housing Benefits, Council Tax Benefit)
		Yes		No

Interests

All Panel members will receive three or four surveys a year. There may be other opportunities to express your views on other issues that are important to you.

Q13

	Listed below are the main priorities for Dacorum's Community Strategy. If the opportunity arises would you be interested in giving your views on any of the following? (please tick all that apply)
		Reducing crime and feeling safe		Cleaner healthier environment
		Planning issues		Climate change
		Social care and health		Local employment issues
		Lifelong learning		Housing needs
		Culture, arts and leisure		Community involvement
		Children and young people		Older people

	Are there any other issues on which you would live to give your views? (Please write in)

How would you like to give your views?

	If you would prefer future correspondence to be in large print, on audio tape, or in another language, will you please tick the relevant boxes below. If you have any other contact preferences will you please write in details :
		In large print
		In another language (Please state which below)
		Other requirement (Please state below)
		Audio

Q14

	From time to time we may wish to contact you by telephone or send you text messages with brief surveys or to tell you about surveys or events you may be interested in. If you would be interested in being contacted in this way please indicate which you may be interested in and write in your telephone numbers below:
		Telephone Surveys		Receiving text messages

	Telephone - Daytime:
	Telephone - Evening:
	Mobile Telephone:

Q15

	Surveys can be sent to you and returned from you by post or we could email the surveys which can then be completed online. If you would be interested in receiving and responding to surveys online please give your email address.
	Email:

Contact Details

	Title (Please tick one box):
		Mr		Mrs		Miss		Ms		Dr

	Family Name
	First Name
	Address Line 1
	Address Line 2
	Town
	County
	Postcode

THANK YOU FOR COMPLETING THE QUESTIONNAIRE.  PLEASE RETURN THIS IN THE ENVELOPE PROVIDED - NO STAMP IS REQUIRED.