If you have any questions about these documents, or if you would like us to help you complete the form, please contact a member of or Policy Development Team on this telephone number (0845) 270 1088 (lo-call).                     Chevin Housing is committed to continuously improving the services that we provide.  We want to make sure that our services are accessible to all of our customers and to make sure that we do not discriminate against anybody on the grounds of age, gender, disability, ethnicity, religion, sexuality or for any other reason that may cause somebody to be treated with prejudice.   So that our services are tailored to the needs of our customers, we are collecting information to make sure that we know what these needs are. We use this information to send out correspondence in a format that suits you, in large print for example. We’ve used this data to plan events for example, a young persons’ event on schemes where we have a concentration of families with children.

We pass on relevant information to our contractors to give them advance notice of mobility issues that may affect the work they do in your home. We are working with high street banks so that we can help tenants access financial advice  and therefore we need to know how many tenants have a bank account. Please will you take a few minutes to complete the short questionnaire enclosed which asks for information about you and your household.  You do not have to tell us this information; if you feel uncomfortable answering any particular question, please leave it blank. All of the information that you give to us will be treated in confidence and in accordance with the Data Protection Act 1998.  The information will be stored on our computer system and will only be accessible to Chevin staff and our partners who are directly involved in providing housing management services to you and your household.

1. Please read the instructions for answering each question carefully. 2. You do not have to answer any sections that you do not wish to complete. 3. If there are more than six people in your household, please email f.herity@chevinha.co.uk or telephone the Policy Development and Service Improvement Team    on 0845 2701088.   4. Please make sure that you complete the correct details for each person throughout the form. For example, if person 3 is 'Joe Smith', the details for Joe should be    completed in the person 3 column on all sections on the form.

Where do you live?

	House name / number
	Address line 1
	Address line 2
	Town / City
	County
	Postcode

Please complete this section for each tenant in your household Tenant 1

Title

Mr

Mrs

Miss

Ms

Other

	First name
	Last name
	Date of birth (e.g. 27/02/83)

Gender

Male

Female

	Tel. number
	Mob. number
	Email address

Do you have a bank account?

Yes

No

Tenant 2 (Joint tenant - if there is no joint tenant please move on to person 3 in the next section)

Title

Mr

Mrs

Miss

Ms

Other

	First name
	Last name
	Date of birth (e.g. 27/02/83)

Gender

Male

Female

	Tel. number
	Mob. number
	Email address

Do you have a bank account?

Yes

No

In this section, please tell us about any other people living with you

Person 3

Title

Mr

Mrs

Miss

Ms

Other

	First name
	Last name
	Date of birth (e.g. 27/02/83)

Gender

Male

Female

	Tel. number
	Mob. number
	Email address

Person 4

Title

Mr

Mrs

Miss

Ms

Other

	First name
	Last name
	Date of birth (e.g. 27/02/83)

Gender

Male

Female

	Tel. number
	Mob. number
	Email address

Person 5

Title

Mr

Mrs

Miss

Ms

Other

	First name
	Last name
	Date of birth (e.g. 27/02/83)

Gender

Male

Female

	Tel. number
	Mob. number
	Email address

Person 6

Title

Mr

Mrs

Miss

Ms

Other

	First name
	Last name
	Date of birth (e.g. 27/02/83)

Gender

Male

Female

	Tel. number
	Mob. number
	Email address

Please describe the ethnic origin of each tenant in the Tenant 1 and 2 columns. Please describe the ethnic origin of each member of your household in the order that they are listed in the previous section in the Person 3 to 6 columns.

	White
		Tenant 1		Tenant 2		Person 3		Person 4		Person 5		Person 6
	White British
	White Irish
	Any other white background
	Mixed race
	Mixed and Black British
	White and Black Caribbean
	White and Black African
	White and Asian
	White and Asian British
	Any other mixed background
	Asian or Asian British
	Asian British
	Indian
	Pakistani
	Bangladeshi
	Any other Asian background
	Black or Black British
	Black British
	Caribbean
	African
	Any other Black background
	Chinese or other ethnic group
	Chinese British
	Chinese
	Any other

	Please identify the religion of each member of your household.
		Tenant 1		Tenant 2		Person 3		Person 4		Person 5		Person 6
	None
	Christian
	Buddhist
	Hindu
	Jewish
	Muslim
	Sikh
	Any other religion

	Please tick as many boxes that apply to you and each member of your household. Please leave blank if not applicable.
		Tenant 1		Tenant 2		Person 3		Person 4		Person 5		Person 6
	Wheelchair user
	Mobility problems
	Learning disability
	Memory problem
	Mental ill health
	Other

	If other, please give details

	Sensory impairment
		Tenant 1		Tenant 2		Person 3		Person 4		Person 5		Person 6
	Sight problems
	Hearing difficulties

	Communication
		Tenant 1		Tenant 2		Person 3		Person 4		Person 5		Person 6
	Difficulty speaking
	Difficulty reading
	Difficulty writing

	Would you like the information you receive to be a different format?
		Tenant 1	Tenant 2
	Large print
	Audio
	Braille
	Other

	If other, please give details

	If English is not your first language, what is your preferred language for Chevin to contact your household?
		Spoken	Written
	Arabic
	Bengali
	Farsi
	French
	Polish
	Punjabi
	Somali
	Urdu
	Other

	If other, please specify

	Please identify your sexual orientation. Please complete this section for tenant(s) only, not children
		Tenant 1	Tenant 2
	Bisexual
	Gay man
	Gay woman / lesbian
	Heterosexual / straight
	Other
	Prefer not to say

	Please describe the employment status of each tenant in the Tenant 1 and 2 columns. Please describe the employment status for each member of your household in the person 3 to 6 columns.
		Tenant 1		Tenant 2		Person 3		Person 4		Person 5		Person 6
	In full time employment
	In part time employment
	Self employed (full or part time)
	Government supported training scheme
	Unemployed and available for work
	Full time education (school / college / university)
	Under school age
	Retired
	Looking after family / home
	Permanently sick / disabled
	Doing something else
	Prefer not to say

CONSENT - PLEASE SIGN THIS SECTION TO SHOW THAT YOU CONSENT TO CHEVIN USING THIS INFORMATION.  ALL THE INFORMATION THAT YOU GIVE IN THIS FORM WILL BE STRICTLY CONFIDENTIAL AND WILL ONLY BE USED BY CHEVIN AND THOSE PARTNERS DIRECTLY INVOLVED IN PROVIDING HOUSING MANAGEMENT AND SERVICES TO YOU. I / we understand that information which I / we have given on this form will be used by the Chevin Housing Group to update details where appropriate.  I / we understand that the information will be used for monitoring purposes to help ensure equality of access to services for all Chevin customers. Please tick the box below to show your consent.

	I consent to Chevin using the information that I have provided as detailed in the paragraph above. This form is completed to the best of my knowledge and belief.
	Yes

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE