Tell us what you think! Now that you have read our draft customer care standards we would like you to tell us whether we have got them right and if not, make suggestions as to how we can make them better.

If you have any queries about the questionnaire or what the information will be used for please do not hesitate to contact Caroline Marshall on 01509 634596 or by e-mail at consultation@charnwood.gov.uk

If you would like us to respond to any of these comments please provide your contact details below.

Name

Address

Post Code

E-Mail

Telephone

You don't need to provide the following information but we would appreciate it if you did because it helps us to know which groups of people we are communicating with and if particular groups of people have similar views, and / or are experiencing similar problems.

Are you ..?
	Male		Female

Which of the following age groups do you belong to? Please tick üone box only
	17 and under		25 to 29 years		45 to 59 years		65 years and over
	18 to 24 years		30 to 44 years		60 to 64 years

Do you or the person/group you are representing have any long standing illness(es), disability(ies) or infirmity(ies)? (long standing means anything that has troubled you over a period of time or that is likely to affect you over a period of time). Please tick üone box only
	Yes		No

To which of these groups do you consider you belong to? Please tick üone box only
	White British		Black or Black British Caribbean
	White Irish		Black or Black British African
	Any other White Background (ü and write in below)		Any other Black or Black British Background (ü and write in below)
	Mixed White & Black Caribbean		Asian Indian
	Mixed White & Black African		Asian Pakistani
	Mixed White & Asian		Asian Bangladeshi
	Any other Mixed Background (ü and write in below)		Any other Asian background (ü and write in below)
	Chinese		Other (ü and write in below)

Thank you very much for taking part in this survey.