Section 1 - Your Details Q1 Title:   Mr   Mrs   Ms   Miss   Other   please specify Q2 First name: Q3 Surname or family name: Q4 Address: Q5 Postcode: Q6 Daytime contact number: Q7 Evening contact phone number: Q8 Mobile phone number: Q9 E-mail: Q10 How would you prefer to participate in Voice?   By telephone   By post   By e-mail/ online
Q11 Are you:   Male   Female		Q12 Date of Birth:

Section 2 - Equalities and Diversity Monitoring Q13 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 Q14 To help us communicate more effectively with our customers please let us know your preferred language if it is not English: Q15 If you have a religion that you would like to inform us of to enable us to take account of your beliefs and customs, please tell us what your religion is: Q16 Do you consider yourself to have any of the following disabilities?   Visual impairment   Wheel chair user   Reduced physical capacity Hearing impairment   Mental illness   Co-ordination difficulties Speech impairment   Learning difficulties   Severe disfigurement

Section 3 - Employment Status Q17 Are you:   Working full-time   Retired Working part-time   A full-time student Looking for work   Long term sick or disabled A homemaker   Other   please specify Section 4 - Tenure Type Q18 Are you:   a General Needs 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 Section 5 - Future Surveys Q19 Are there any specific topics that you would like to be surveyed on in the future? Thank you for taking the time to complete this questionnaire.