Torfaen People's Panel is a chance for you to have a say about life in Torfaen and the services you receive.  The People's Panel is being set up by the Council, Local Health Board, Gwent Police and Torfaen Voluntary Alliance and as a member of the Panel you will inform decisions made by those organisations. There will be a range of topics and activities for you to take part in, such as surveys, community workshops, focus groups and online discussions.  You may also be invited to test our services by making ‘mystery shopping’ visits.

To ensure that the Panel mirrors the population of Torfaen, people are selected on the basis of age, gender, ethnicity, disability and where in Torfaen they live.  To keep the panel innovative we are always inviting more people to join.  Anyone aged 16 or over is invited to apply.

If you would like any further information, please contact Julia Rooney, Principle Public Engagement Officer on 01495 766159 or e-mail julia.rooney@torfaen.gov.uk Thank you.

	Are you a resident of Torfaen?
	--Click Here--YesNo

You MUST be a resident of Torfaen to qualify for applying to become a member of  the Torfaen People's Panel. If you are a resident of Torfaen please change your answer to 'Yes' to continue with the application. If you are not a resident of Torfaen you cannot procede any further with this application, however, you may wish to contact your local authority to ask whether they have a citizen's panel;  please close this browser window to cancel this application. Thank you.

Q1.	Title:
	--Click Here--MrMrsMissMsDrRevOther

	Other (please specify)

Q2.	First name(s):

Q3.	Surname:

Q4.	Address:

Q5.	Postcode:

Q6.	Landline telephone number: PLEASE ENTER AS 11 DIGITS SEPARATING THE STD CODE WITH A SPACE e.g. 01633 123456

Q7.	Mobile telephone number: PLEASE ENTER AS 11 DIGITS WITH NO SPACES e.g. 07890123456

Q8.	Email address:

Q9.	We would prefer to contact you by email.  Are you happy with this?
	--Click Here--YesNo

Q10.	If you don't have an email address or are not happy for us to contact you by email, how would you like us to contact you? TICK ALL THAT APPLY
	By post
	By post - Large print
	By landline phone
	By mobile phone

Q11.	Date of birth (dd/mm/yyyy):

Q12.	Gender:
	--Click Here--MaleFemaleTransgender

Q13.	How did you first find out about the Torfaen People's Panel?
	--Click Here--Internet search engineTorfaen council's website - Torfaen.gov.ukNewspaper - South Wales ArgusCouncil newspaper - Torfaen TalksLetter to your homePosterCouncil payslipCouncil Customer Care OfficerTafod - voluntary sector newsletterPolice community support officer (PCSO)Word of mouthOther

	If other please specify:

Your household

Q14.	How would you describe your household?
	--Click Here--Single person without dependant childrenSingle person with dependant childrenCouple without dependant childrenCouple with dependant childrenOther household group without dependant childrenOther household group with dependant childrenLive with parents/guardian

Q15.	Are you an employee of...?
	--Click Here--Torfaen County Borough CouncilGwent PoliceTorfaen Voluntary AllianceAneurin Bevan Health BoardNone of the above

Q16.	Which of the following best describes your employment status?
	--Click Here--Working full timeWorking part timeSelf employedGovernment training schemeFull time educationPermanently sick/disabledUnemployed - available for workRetiredLooking after the homeCaring for a child or adultOtherwise not working

Q17.	Is your home...?
	--Click Here--Owned outright (no mortgage or loan)Owned with mortgage or loanRented from Bron Afon (previously Torfaen Council)Rented from a housing associationRented from a private landlordOther

	Other (please specify):

Q18.	How many children under the age of 18 do you have?
	--Click Here--None12345+

We will seek to ensure that no one receives less favourable treatment on the grounds of disability, race, language, gender, colour, religion, age, sexual orientation, marital status, social position, or any other improper grounds, by any requirements or regulations which cannot be fully and legally justified.

Disability/illness

Q19.	Do you have a long-standing illness, disability or infirmity i.e. something that has an adverse effect on your ability to carry out normal day-to-day activities?
	--Click Here--YesNo

Q20.	Which of the following best describes your illness, disability or infirmity? TICK ALL THAT APPLY
	Hearing impaired
	Visually impaired
	Physical disability
	Learning disability
	Mental health disability
	Other

	Other (please specify):

Language

Q21.	What would you consider to be your main language?
	--Click Here--EnglishWelshOther

	Other (please specify):

Q22.	In which language would you prefer to receive communication?
	--Click Here--EnglishWelsh

Q23.	Can you understand, speak, read or write Welsh? PLEASE TICK ALL THAT APPLY
	Understand spoken Welsh
	Speak Welsh
	Read Welsh
	Write Welsh
	Currently learning Welsh
	None of the above

Sexual Orientation

Q24.	What is your sexual orientation?
	--Click Here--HeterosexualGay / Lesbian / BisexualPrefer not to say

Religious Belief

Q25.	Do you have a religious belief?
	--Click Here--YesNoPrefer not to say

Q26.	Please state what your religious belief is:

Ethnicity

Q27.	What would you consider your national identity to be?
	--Click Here--WelshEnglishScottishIrishBritishOther

	Other (please specify):

Q28.

The ethnic groups set out below are those advised by the Equality and Human Rights Commission.  They are not concerned with nationality (which is why there is no "Welsh" category), but seek to identify ethnic groups.  UK citizens can belong to any of these groups. How would you describe your ethnic origin?

--Click Here--White - BritishWhite - IrishAny other white backgroundBlack & Black British - CaribbeanBlack & Black British - AfricanAny other Black backgroundAsian & Asian British - IndianAsian & Asian British - PakistaniAsian & Asian British - BangladeshiAny other Asian backgroundMixed Race - White & Black CaribbeanMixed Race - White & Black AfricanMixed Race - White & AsianAny other Mixed backgroundChineseOther ethnic group

Q29.	What topics of consultation are you interested in? PLEASE TICK ALL THAT APPLY
	Advice & benefits
	Business
	Community & living
	Council & democracy
	Education & Learning
	Environment & planning
	Health & social care
	Housing
	Leisure & culture
	Policing
	Transport & streets

Please click the SUBMIT button once to complete the survey Thank you for your time! If you have any queries please call Julia Rooney on 01495-766159 or email julia.rooney@torfaen.gov.uk