Citizen Panel Recruitment Form 2011
In order to ensure our sample of panel members reflects the population of Staffordshire,
could you please complete this recruitment form by answering the following questions.
This information will help us to monitor trends in issues raised by different groups.
Forename
Surname
Address line 1
Address line 2
Address line 3
Postcode
Home telephone number
Mobile telephone number
Work telephone number
Email
(this will ONLY be used to send questionnaires and other material relating to Staffordshire Police's Citizens' Panel)
What is your sex?
Male
Female
What is your date of Birth (DD/MM/YYYY)
How would you describe your sexual orientation?
Bisexual
Gay man
Gay woman/lesbian
Heterosexual/straight
Other
Prefer not to say
What is your religion/belief?
What is your ethnic group?
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background
Black or Black British
Caribbean
African
Any other Black background
Chinese
Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background
White
White
British
Irish
Any other White background
Other ethnic background
Do not wish to say
In which district council area do you live?
Staffordshire Moorlands
Newcastle
Tamworth
Lichfield
Stafford
East Staffordshire
Cannock Chase
South Staffordshire
Stoke City Council
Do you have a long-term illness, health problem or disability which limits your daily activity or the work you can do?
Yes
No
The information supplied in this form will be kept by Staffordshire Police and used for Citizens' Panel purposes. All personal data will be collected, stored and treated with complete confidentiality in line with the Data Protection Act 1998 i.e. it will not be shared with third parties. The Data Protection Act 1998 regulates the collection, storage, processing and disclosure of personal data and also gives rights to individuals about whom information is recorded.
Please tick the box below to indicate you voluntary agreement to become a member of the Citizens' Panel
Thank you for taking the time to complete this form.
All information will be treated in the strictest confidence
