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Epsom & Ewell Citizens' Panel Membership Form
Please complete all the details below. Completing this information now will ensure that you are not asked these questions each time you complete a survey.  This information will enable the Council to make sure that the panel is representative of different age groups, gender, ethnicity, employment status, geographical location and housing tenure, for example.  Please be assured that individual information will remain confidential with the Council's Consultation & Communications Team. All information stored on our database is held in strict compliance with the Data Protection Act 1998.
  Please state your title: Please tick one box only.
  Please state the ward you live in Please tick one box only.
  Do you have access to the Internet from a computer at home?
Please note that the most cost-effective way for the council to consult is via email, as this will save paper, postage and data input costs.
  What is your preferred correspondence method for consultation purposes?
  Are you...
  How long have you been living in the Borough of Epsom & Ewell? Please tick one option only
  How long have you been living in your current accommodation? Please tick one option only.
  Which of these activities best describes what you are doing at present? Please tick one box only.
  Do you work in the Borough of Epsom & Ewell?
  Ethnic Group Please tick one box.
  What is your religion / belief?  Please tick one box only.
  Do you have a long-standing illness or disability?  (Long-standing means anything that has troubled you over a period of time or that is likely to affect you over a period of time).  
  Which of the following describes your marital status?  Please tick one box only.
  Which of the following best describes your home?  Please tick one box only.
  Which of these option best describes your current accommodation? Please tick one box only.
  Which of the following best describes your home situation?  Please tick one box only.
  How many people are there in your household (including yourself and any children)?  
Please indicate the number of people in each age group.
  Aged 0 - 4          
  Aged 5 - 10          
  Aged 11 - 15          
  Aged 16 - 18          
  Aged 19 - 64          
  Aged 65+          
  From time to time, the Council may wish to hold other types of consultation (other than surveys) with residents on the Citizens' Panel to gain feedback about our services or other local issues. Please indicate whether or not you would be prepared to take part in any of the following:
Please tick all that apply
Epsom & Ewell Borough Council is committed to equal opportunities and treating all residents fairly. As part of The Equalities Act 2010, we are required by government to publish Equal Opportunities Monitoring reports. This is to ensure that the Council treat all residents fairly and equally. Please help us monitor our progress by filling the information below because we use the information you provide as part of our decision making process,
however you are not obliged to answer them.  Thank you
  Do you consider yourself to be....
  Do you identify yourself as a.... (please tick all that apply)
  Is your gender identity different from the sex you were assigned at birth?
Thank you for completing this questionnaire!
Your name, address, telephone number and email address will not be used for any other purpose except for use by the Council's Consultation & Communications Team for the running and management of this panel (as specified under the Data Protection Act 1998), and the identity of individual respondents will not be revealed.  All data collected using the Citizens Panel will be treated in the strictest of confidence and will only be used to monitor the services offered by Epsom & Ewell Borough Council and its partners.  Anonymised responses to some questionnaires may be shared with partner agencies (for example, Surrey Police, South East of England Development Agency, the Local Strategic Partnership).

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