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* 1. I feel confident that I can make a change in my community

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* 2. I feel my voice is valued

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* 3. I feel part of a community

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* 4. I know how to influence decisions that make a difference to me

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* 5. In the last 12 months have you taken part in any activities or projects in your community? If so, what were they? This could include activities like campaigning, fundraising or volunteering.

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* 6. 3. Is there anything that would empower you to feel more involved in your community?

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* 7. What is your date of birth?

Date

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* 8. What is your postcode

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* 9. Do you consider yourself to have a disability? 

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