Dacorum Borough Council would like to invite you to join a panel of residents to take part in regular consultations. As a panel member you will be asked to complete three or four postal questionnaires a year about public services in the region, and will be provided with the opportunity to positively contribute to the development of your local community.

The Citizens Panel is a useful way for us to learn views and opinions of local people on important issues. The questionnaires are interesting and easy to complete, and Panel members receive regular feedback about the survey results.

We have asked Opinion Research Services, an independent company, to manage the Panel on our behalf. All information is collected and maintained by Opinion Research Services and passed on to us. This information will be kept in the strictest confidence, will not be passed on to any third party and will be used for research purposes only.

If you have any questions about the Panel or the recruitment process, please do not hesitate to contact Opinion Research Services on 01792 535300 or myself, Claire McKnight, at Dacorum Borough Council on 01442 228619.

How would you prefer to receive your panel questionnaires?
(Select as many options as apply)

By post
By email
In large print
In a language other then English (Please specify)
Other (Please write in)

About You

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

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

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)

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
No

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

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

White: British	Asian or Asian British: Indian
White: Irish	Asian or Asian British: Pakistani
White: Other (Please write in)	Asian or Asian British: Bangladeshi
Mixed: White and Black Carribean	Asian or Asian British: Other (Please write in)
Mixed: White and Black African	Black or Black British: Carribean
Mixed: White and Asian	Black or Black British: African
Mixed: Other (Please write in)	Black or Black British: Other (Please write in)
	Chinese
	Other (Please write in)

Are you an employee or Councillor of Dacorum Borough Council?
(Select all that apply)
Yes - employee
Yes - councillor
No - neither of these

Dacorum Card

Do you have a 'Dacorum Card'?
(Select one option only)
Yes
No

If you do not have a Dacorum Card - Do you receive means-tested benefits? (e.g. Housing Benefit, Council Tax Benefit
(Select one option only)
Yes
No

Further Consulatation

Would you be willing to take part in further consultations with Dacorum Borough Council in the future?
This could be group discussions or online consultations. (Select one option only)
Yes
No

Contact Details


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

Telephone number:
Email address: