Section 1 -  Your Participation Method

How would you prefer to receive any draft publications?
By post		By email

Occasionally, we hold small Focus Groups to discuss any draft publications. Would you be interested in attending any of these?
Yes		No

Section 2 - Your Details

Title:

Mr

Mrs

Ms

Miss

Other

If other, please specify

First Name:

Surname:

Address:

Postcode:

Contact Number:

Email:

Are you:	A General Needs rented tenant of the Association
	A Sheltered Housing tenant of the Association
	A Leaseholder or Shared Owner of the Association
	A Keyworker resident
	A licencee of temporary accommodation
	A Market Rental tenant via Commercial Services

Section 3 - Equality and Diversity Monitoring

You may choose not to complete the following demographic questions; however this information ensures we know more about the needs of our residents and helps us tailor our services to meet your needs. It also allows us to analyse any feedback from sub-groups of the overall population. All individual demographic information is treated as confidential.

What is your preferred method of communication?
Post		Email		Telephone		Type Talk		Face to Face

To help us communicate more effectively with our customers please let us know your preferred language if it is not English:

Are you:

Male

Female

Date of Birth:

Please look at the following list and tick the box that best applies to your ethnicity:
White - British		Asian or Asian British - Pakistani
White - Irish		Asian or Asian British - Bangladeshi
White - Other		Asian or Asian British - Other
Mixed - White and Black Caribbean		Black or Black British - Caribbean
Mixed - White and Black African		Black or Black British - African
Mixed - White and Asian		Black or Black British - Other
Mixed - Other		Chinese
Asian or Asian British - Indian		Other

What is your religion?
None		Hindu		Sikh
Christian (All denominations)		Jewish		Any other religion
Buddhist		Muslim

If Any other religion, please specify

Do you consider yourself to have any of the following disabilities?
Visual impairment		Wheel chair user		Sever disfigurement
Hearing impairment		Learning difficulties		None
Speech impairment		Reduced physical capacity

Are you:
Working full-time		A homemaker		Long term sick or disabled
Working part-time		Retired		Other
Looking for work		A full-time student

If other, please specify

Thank you for completing the Publications Group Membership Survey and for the interest you have shown in becoming involved. We will be in contact with you shortly to confirm your membership and send you a Welcome Pack.