Panel Recruitment Survey
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1. Amber Valley Consultation Panel

This questionnaire asks you for information about you and your household, we need these details to make sure that the Amber Valley Consultation Panel represents all the people in Derbyshire. If you would like to take part in the Amber Valley Consultation Panel, please fill in the questionnaire.

We will treat all information that you give in the strictest confidence. Your identity will never be revealed, or passed to another agency outside the partnership.

1. Would you like to take part in the Consultation Panel?

Would you like to take part in the Consultation Panel? Yes

Member of Existing Panel

2. How would you like to be involved? (Please choose as many options as you would like)

How would you like to be involved? (Please choose as many options as you would like) Receiving up to six questionnaires a year by post, to respond in a freepost envelope

Receiving questionnaires by Email

Occasional questions by telephone

Informal meetings with small groups of Panel Members

Face to face interviews

3. If you are interested in receiving questionnaires by Email please enter your Email address below

If you are interested in receiving questionnaires by Email please enter your Email address below Email Address:

4. What topics are you interested in being consulted on?
(Please choose all that apply)

What topics are you interested in being consulted on? (Please choose all that apply) About my area and community

Crime and community safety (including road safety)

Services for children, families and younger adults

Services for adults

Health

Education services

Environmental issues

Economy and jobs

Highways and transport

Housing

Arts, culture and leisure

Budget setting and service priorities

All of the above

Other (please specify)

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