BME Residents Panel - Registration Form

Firstly, can I confirm your ethnic origin?

How satisfied would you say you are with your local area as a place to live?

Which three things would most improve the quality of life in the area where you live?

1 2 3

Which of the following NHS services have you used in the last 12 months and how good or poor were these services?

Now we would like to find out a little bit of information about you.
This will help us to make sure the panel includes people from a range of backgrounds.

Specify your age:

Specify your gender:

Specify your maritul status:

How many adults (over 16) and children (under 16)  are there in your household?

How long have you lived in your neighbourhood?

years

Are you

Do you have any disabilities or health problems, which limit your everyday activities in any way?

Please provide your name and address for correspondence:

Name: Address: Telephone/Mobile:

How would you prefer to be contacted about the panel: (choose one)

What is your first language?

From time to time, you may be asked if you would like to take part in group discussions or focus groups. To help us tailor these offers to your interests, please tell us which of the following services you have used within the last 12 months?

The information supplied on this form will be stored electronically by BBEMI and Public Sector Organisations in Barnsley. Your details will only be used for the purposes of the BME Residents Panel and will NOT be passed on to any third party.

I agree to my information being used for this purpose.