1.	FIRST NAME*

2.	SURNAME*

3.	ADDRESS*
	Address 1   Address 2   Address 3   Postcode

4.	Telephone number

5.	Email Address

6.	DATE OF BIRTH
	dd/mm/yyyy

7.	GENDER*
	Male    Female

8.	Please indicate what issues you are interested in? Please tick all that apply
	Community Safety    Environment    Health & Wellbeing    Regeneration & Economy    Education & Skills    Children & Young People    Older People    Other, please specify

9.	How would you prefer to contribute your views? Select at least 1 and no more than 6.
	A questionnaire in the post to complete    A telephone interview    A meeting during the evening    A meeting during the day    An Internet or email based survey    Do you have any other suggestions?

10.	Do you consider yourself to be disabled? The definition of disabiliy as defined under the Disablity Discrimination Act is a "physical or mental impairment which has a substantial and long term adverse effect on ability to carry out normal day to day activities"
	Yes No

11.	If yes, how would you describe your disability or long-term health condition? Please tick all that apply
	Sensory impairment    Mental health problem    Mobility impairment    Learning disability    Mental health condition    Long standing illness or health condition

12.	Ethnic Group Please tick one box only
	WHITE - British WHITE - English WHITE - Scottish WHITE - Welsh WHITE - Irish WHITE - Other (please state in box below) MIXED - White & Black Caribbean MIXED - White & Black African MIXED - White & Asian MIXED - Other (please state in box below) ASIAN - Indian ASIAN - Pakistani ASIAN - Bangladeshi ASIAN - Chinese ASIAN - Other (please state in box below) BLACK - Caribbean BLACK - African BLACK - Other (please state in box below) OTHER ETHNIC GROUP - (Please state in box below) Other, please specify

13.	In what language would you prefer to consult with Rhondda Cynon Taf?
	English    Welsh    Other, please specify