We will treat all information that you give in the strictest confidence. Your identity will never be revealed, or passed to another agencyoutside the partnership.
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This questionnaire asks you for information about you and your household, we need these details to make sure that the High Peak Citizens' Panel represents all the people in High Peak.

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High Peak Citizens' Panel
Would you like to take part in the Citizens' Panel?
Yes
No
Member of Existing Citizens' Panel
How would you like to be involved?
Description
Time required
X if interested
Receiving up to six questionnaires a year
by post, to respond in a freepost envelope
One hour per year
Face to face interviews
Occasional questions by telephone
Informal meetings with small groups
of Panel members
One hour per month
Two hours per year
Three hours per year




Receiving questionnaires by e-mail
One hour per year

About my area and community
Crime and community safety
Services for children, families and younger adults
Services for adults
Health
Education services
Environmental issues
Economy and jobs
Highways and transport
Housing
Arts, culture and leisure
Budget setting and service priorities
Other (Please X and specify below)
All of the above
What topics are you interested in being consulted on?
(including road safety)
If you are interested in receiving questionnaires and newsletters by e-mail please enter your e-mail address below.
A disabled person is someone who has a physical or mental impairment which has a substantial or long term adverse effect on their ability to carry out day to day activities.    Do you consider yourself to have a disability?
No
Yes, affecting mobility
Yes, affecting hearing
Yes, affecting vision
Yes, a learning disability
Other (Please X and specify below)
Which of these activities best describes what you do at present?
Employed full-time (30 hours or more)
Employed part-time (less than 30 hours)
Self-employed full or part-time
Unemployed and available for work
Looking after the home
Wholly retired from work
On a Government training scheme
Full-time education
Carer
Permanently sick/disabled
Doing something else (Please specify below)
Are you employed by any of the following organisations?
Any Derbyshire District/Borough Council
Derbyshire County Council
Derbyshire Constabulary
Other Local Authority
Which of these options best describes how you think of yourself?
Heterosexual/straight
Gay/lesbian
Bisexual
Other
Prefer not to say
The following questions are about you and your household.  Please answer all the questions as
fully as you can.
Are you?
Male
Female
Please describe yourself:
16 to 17 years
18 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 59 years
60 to 64 years
65 to 74 years
75 years and over
YOU AND YOUR HOUSEHOLD
Is your house / flat:
Owned or mortgaged by you / family
Rented from a Housing Association
Rented from the council
Rented from a private landlord
Other (Please X and specify)
Christian (including Church of England, Catholic,
Buddhist
Hindu
Jewish
Muslim
Sikh
Any other Religion (Please X and specify)
No Religion at all
Protestant & all other Christian denominations)
What is your Religion, even if you are not currently practising?
Please describe yourself:
British
Irish
Any other white background (Please specify)
White & Black Caribbean
White & Black African
White & Asian
Any other mixed background (Please specify)
Caribbean
African
Any other black background (Please specify)
Indian
Pakistani
Bangladeshi
Any other Asian background (Please specify)
Chinese
Any other ethnic background (Please specify)
White
Mixed
Black or Black British
Asian or Asian British
How many cars (including vans) are available for use at this address?
None
One
Two
Three or more
Do you have any dependent children?
Yes
No
Please write in your phone number including the area code:
(
) (
Are there any children aged between 11 and 15 in your household who you would be willing to take part in surveys for young people?
Can you please provide us with your contact details:
Title:
Address:
Please use this space if you wish to make any further comments:
Thank you for agreeing to become a member of the High Peak Citizens' Panel
Yes
No
Mr
Mrs
Ms
Miss
Other (Please specify)
Please write -  dd/mm/yy
First name
Surname
Postcode
Date of birth