Residents’ Panel recruitment survey

About you

The following questions will help us to see if you match the requirements for our panel. It would help us if you answer every question that is applicable to you. If you don't want to answer a question please select the prefer not to say option or leave the answer blank.

Q1	Are you....? Please select one answer

Q2	Is your gender identity the same as the gender you were assigned at birth? Please select one answer

Q3

What is your date of birth? (dd/mm/yyyy)

Q4	To which of these ethnic groups do you feel you belong? Please select one answer

*If your ethnic group was not specified in the list please describe your ethnic group.

The Equality Act 2010 considers a person disabled if they have a longstanding physical or mental condition that has lasted or is likely to last at least 12 months; and this condition has a substantial adverse effect on their ability to carry out normal day to day activities. People with some conditions (cancer, multiple sclerosis and HIV/AIDS, for example) are considered to be disabled from the point that they are diagnosed.

Q5	Do you consider yourself to be disabled as set out in the Equality Act 2010? Please select one answer

Q5a

If you replied yes to Q5, please tell us the type of impairment that applies to you. You may have more than one type of impairment, so please select all that apply. If none of these apply to you please select other and write in the type of impairment you have.

Physical impairment

Sensory impairment (hearing and sight)

Longstanding illness or health condition such as cancer, HIV, heart disease, diabetes or epilepsy

Mental health condition

Learning disability

Prefer not to say

Other

Please provide details

Q6	Do you regard yourself as belonging to any particular religion or belief. Please select one answer

Q6a	If you answered yes to Q6 which one? Please select one answer

Please provide details

Q7	Are you...? Please select one answer

Q8	Which of the following activities best describe what you are doing at present? Please select one answer

Please provide details

Q9	What is or was your occupation?

Q10	How long have you lived in East Sussex. Please select one answer

Q11	Which of the statements below best describes the make up of your household? Please select one answer

Please provide details

Q11b	If you indicated in Q11 that you have children in your household, how many do you have and what are their ages?

How do you want to be involved?

The following questions will help us to find out how and when you like to be consulted.

Q12	Thinking about the various consultation activities we undertake, how often would you like to take part in the following? Please select all that apply
Q12		I wouldn't	once a year	two or three times a year	three or four times a year	four or more times a year
	Face to face interviews
	Face to face surveys
	Telephone interviews
	Telephone surveys
	Postal surveys
	Electronic surveys
	Small discussion groups
	Community Workshops

Q13

If you chose to take part in face to face activities such as discussion groups, interviews or surveys what time of day would you prefer that contact to take place? Please select all that apply

Morning

Afternoon

Early evening

Any time of day

Your contact details

Q14	Title

Please provide details

Q15	Christian Name

Q16	Surname

Q17	Address 1

Q18	Address 2

Q19	Town

Q20	Postcode

Q21	Telephone number

Q22	Email address

Your Consent

We need you to confirm that you are happy to join ‘Expressions’, the East Sussex County Council’s Residents’ Panel and that you authorise the use of your data for the purposes stated below:

I am aware that the answers I give in response to any Residents’ Panel activity I take part in will be processed by the Council (or a third party if and when the need arises) to find out what East Sussex residents think about Council services and other important issues affecting life in East Sussex. The information may be used to inform the planning and delivery of Council services or to inform the development and implementation of Council policy.

Q23

I am happy to join East Sussex County Council’s Residents Panel

Yes

No

Q24

I authorise East Sussex County Council to use the data for the purposes stated above

Yes

No