Welcome to Hertfordshire's Citizens' Panel.

Opinion Research Services is an independent social research company recruiting and managing Hertfordshire's Citizens' Panel on behalf of the council. We hope you will join the Citizens' Panel because it is a valuable opportunity to give your views on a wide range of important issues, including council services and priorities, policing and health services. If you join, you will be invited to complete periodic short questionnaires (10 minutes, three or four a year) and have a chance to take part in occasional discussion groups.

Anybody aged 16 or over can be a panel member. We need to ask the questions below to ensure that the Panel is representative of the Hertfordshire population and so we may consult you on issues of particular relevance. ORS is regulated by Data Protection legislation, promises to keep your details confidential; no information will be passed to third parties without your permission and the information you provide will be used for research purposes only.

About You

A1. For each person in your household, including yourself, please state their age and sex in the paired boxes below.

You		Person 2		Person 3		Person 4

Gender	Age	Gender	Age	Gender	Age	Gender	Age


Person 5		Person 6		Person 7		Person 8
Gender	Age	Gender	Age	Gender	Age	Gender	Age

A2a. 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. (Select one option only)
Yes -Please continue to question A2b
No -Please go to question A3

A2b. If yes, Does this illness or disability (do any of these illnesses or disabilities) limit your activities in any way?
(Select one option only)
Yes
No

A2c. How does this illness, disability or infirmity affect you?
(Select all that apply)

Vision
Speech
Mental health
Learning difficulty
Hearing
Movement
Other (Please write in)

A3. Do you regularly look after, or give unpaid help or support to any of the following...? Please do not count anything that you do as part of your paid employment.
(Select all that apply)
Disabled child
Disabled partner
Elderly relative
Friends
Neighbours
Other
None

A4. Which of these activities best describes what you are doing at present?
(Select one option only)
Working and...
...Full time employee (30 hours/week or more)
...Part time employee (less than 30 hours/week)
...Self employed
Not working and...
...Retired
...Looking after home
...Unemployed - available for work
...Government training scheme
...Full time student
...Permanently sick/disabled
...Otherwise not working

A5. What is your ethnic group?
(Select one option only)

White: British	Asian/Asian British: Bangladeshi
White: Irish	Asian/Asian British: Chinese
White: Gypsy or Traveller	Asian/Asian British: Other (please specify)
White: Other (please specify)	Black/Black British: Caribbean
Mixed: White and Black Caribbean	Black/Black British: African
Mixed: White and Black African	Black/Black British: Other (please specify)
Mixed: White and Asian	Other Ethnic Group: Arab
Mixed: Other (please specify)	Other Ethnic Group: Other (please specify)
Asian/Asian British: Indian	Prefer not to say
Asian/Asian British: Pakistani

A6. In which of these ways does your household occupy your current accommodation?
(Select one option only)

Owned outright (no mortgage or loan)
Owned with mortgage or loan
Rented from the Council
Rented from a Housing Association
Rented from a Private Landlord
Other (Please write in)

A7. Which of the following represents the total annual income of your whole household, before deduction for Income Tax, National Insurance, etc?
(Select one option only)
Prefer not to say
Up to £14,999
£15,000 up to £34,999
£35,000 up to £59,999
£60,000 and over
Don't know

A8. In the last 12 months have you, or any member of your household used any of the following services?
(Select all that apply)
Education Services (Primary)	Libraries
Education Services (Secondary)	Hertfordshire County Council Website (http://www.hertsdirect.org/)
Social care services for children and young people	Registration of births, deaths, marriages, civil partnerships and citizenship
Care and support for people with physical disabilities	Fire and rescue preventative services
Care and support for people with learning disabilities	Fire and rescue emergency services
Care and support for people with mental health problems	Local public transport information
Care and support for older people	The local bus service
Household Waste Recycling sites	None of the above
Trading standards

Future Contact

B1. How would you prefer to conduct your panel questionnaires and receive feedback?
(Select all that apply)

By Post
Online/e-mail (please ensure you provide your e-mail address below)
In larger print
Other preference (please specify)

B2. We would like to send you Hertfordshire County Council news by email - so please indicate if you would like us to provide this service by email?
(Select one option only)
Yes, please send me news circulars from Herts CC (please ensure you provide your e-mail address below)
No, I do not require this service

Your Details


Title:
Forename:
Surname:
Address 1:
Address 2:
Address 3:
Address 4:
Postcode:

Daytime Telephone number:
Alternative Telephone number:

Email address:
Retype Email address: