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Citizens' Panel
Citizens' Panel Entry Form
Name
*
Address
Postcode
Telephone No.
Mobile No.
Email
Date of birth (DD/MM/YYYY)
*
Are you?
Please Select
Male
Female
Which types of consultation would you prefer to be involved in?
Postal questionnaires
Telephone interviews
Face to face interviews
Email questionnaires
Website surveys
Message board discussions on the internet
Text messaging
Focus groups
Public meetings and debates
Other (please specify)
What are your top five areas of interest when it comes to Council consultations?
The environment
Education
Leisure
Sport
Tourism
Transportation
Commerce
The countryside
Urban regeneration
Crime
Health
Social Services
How would you describe your working status?
Unemployed
In full-time employment
In part-time employment
Self-employed
In full-time education
In part-time education
Retired
How would you describe your ethnic background?
White British
White Other
Black British
Black Other
Asian British
Asian Other
Other (please specify)
Do you have a disability?
Yes
No
If yes, please specify
Would you prefer to be contacted in Welsh?
Yes
No
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