Three Rivers Housing Association Customer Survey

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1 Three Rivers Housing Association Customer Survey Q1. Address Q2. Postcode Tenancy Ref (if known) Q3. Daytime Phone Number Q4. Evening Phone Number Q5. Mobile Phone Number Q6. Do you have internet access? Yes Q7. address Please use the tables below and on the next page to tell us about the people in your household. There is enough space to provide details of up to 6 people living in your household. If there are more than 6 people in your household please provide their details on a separate sheet of paper or contact our customer services team on to provide the information over the phone. Person 1 Q8. First Name Q10. Date of birth Q9.Last Name Q11. National Insurance Number (If over 16yr old) Q12. Gender Person 2 Q13. First Name Q15. Date of birth Q14. Last Name Q16. National Insurance Number (If over 16yr old) Q17. Gender Page 1 of 6

2 Person 3 Q18. First Name Q20. Date of birth Q19. Last Name Q21. National Insurance Number (If over 16yr old) Q22. Gender Person 4 Q23. First Name Q25. Date of birth Q24. Last Name Q26. National Insurance Number (If over 16yr old) Q27. Gender Person 5 Q28. First Name Q30. Date of birth Q29. Last Name Q31. National Insurance Number (If over 16yr old) Q32. Gender Person 6 Q33. First Name Q35. Date of birth Q34. Last Name Q36. National Insurance Number (If over 16yr old) Q37. Gender Page 2 of 6

3 Q38. Which format would you like to receive information in? TICK ONE ONLY special requirements 6 Black print on yellow paper Large print 7 Text Message 3 8 DVD 4 Audio cassette tape 9 Plain English 5 CD 0 Picture format 1 (please give details) Q39 Is English your first language? Yes Q40. If English is not your first language what language would you like us to communicate with you in? Q41.And would you prefer written or spoken communications? Written Spoken Q42. Are you interested in getting involved in or being consulted about Three Rivers policies or about issues which affect in your local area? Yes Q43. How would you like to get involved? Internet One-off meetings Regular meetings Text messaging Postal surveys Telephone surveys (please give details below) Page 3 of 6

4 Q44. How would you describe your household's ethnicity? (If there is more than one ethnicity within your household please tell us about all that apply) White Mixed British White and Black Caribbean Eastern European White and Black African Irish White and Asian Asian or Asian British Black or Black British Indian Caribbean Pakistani African Bangladeshi Chinese Ethnic Group Chinese Q45. How would you describe your household's faith or religious belief? (If there is more than one faith or religion within your household please tell us about all that apply) e.g. Christian, Muslim, etc. WRITE IN Page 4 of 6

5 Q46. How would you describe the sexual orientation of your household? (If there is more than one sexual orientation within your household then please tick all that apply) Straight / heterosexual Bi-sexual Gay man Lesbian Q47. Do you or any household member consider yourselves to: Have mobility or physical difficulties Have hearing or speech difficulties Have sight and vision difficulties Have issues with mental health Have learning, literacy or numeracy needs. Q48. Does your home have any of the following adaptations? Access ramp to the front door Stair lift Access ramp to the back door Walk in shower Extra handrail fitted on the stairs Adapted bath Bathroom grabrail Tap adaptation (please provide details) Q49. Are there any ways in which you think we could support you in your home? This may include help with debt or benefits advice, support if you have recently left care, help with understanding letters and documents you have received, help if you are suffering harassment or domestic violence etc. TICK ONE ONLY Yes Q50. If yes please let us know the nature of the support you may require. WRITE IN Page 5 of 6

6 Q51. t having a bank account means that you may pay more to manage your money, will not be able to take advantage of cheaper bills by paying through direct debit, and may find it harder to plan for a secure future. In order to help us find out whether this is a problem for our customers please tell us whether you have a bank account? Yes 3 Q52. To help us ensure that your personal information is kept secure please answer one of the following security questions: (You may be asked to answer this question before we discuss your application for housing, tenancy or other personal information with you.) What is your mother s maiden name? What is your place of birth? Where was your first school? Q53. If you have helped someone to fill in this form, please provide your contact details: Name Phone Thank you for your help Page 6 of 6

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