Panel and Members Confidential Enquiry Questionnaire

This form can be automatically translated into many different languages by clicking the translate facility

Please help by becoming a One Norbiton Consultant

We hope to make our ward into one of the best places to live work or study in but to do this properly we need information. In 2013 we asked for data from only 150 addresses (but random and therefore representative). Now we are asking help from everyone in Norbiton as well as this Panel.
So please would you and all those members in your household who would like to build up the community feeling here, share a few details about themselves.
This should only take a few minutes of your time and we promise that any information you give us will be kept strictly private and anonymous. It will never be used for commercial purpose or in any way you do not want. Here is a paper on the validity the Happiness Scale and Summary of this

Have you heard about One Norbiton before?
If yes, where from?
1. Can you read and understand English?
2. If not, would you like help answering this questionnaire?
3. Have you tried our Website translator?
4. Are you happy to be our consultant?
5. What is your date of birth?
6a. (Optional) First name or initial?
6b. (Optional) Family name or initial?
7. Please tick if you are
8. What year did you start living in Norbiton?
9. How many years do you expect to stay here?
10. Who owns your house?
11. How many generations live in your household?
12. What is your Employment Status?

13. Do you often feel lonely?
If yes, whom can you rely on for support if things go wrong?

14. Do you often feel worried or under a lot of stress?
If yes, what causes it (Please tick all answers that apply to you)?
14b. What health problems do you have now
(Please tick all that apply to you)
15. If in Debt do you have an expensive high interest Payday Loan?
16. Do you ever have to choose between paying for food or heating your home?
17. We are lucky that a new Community Bank – Surrey Save – has just started to operate in Norbiton. This offers borrowing and saving at a fair rate of interest. Would you like to learn more about it?
18. How happy or unhappy are you generally about living in Norbiton?Click the button under the face below as an easy way of recording how you feel.
0 10 20 30 40 50 60 70 80 90 100
19. Do you fear that delay in getting Universal Credit will stress you?
20. Even if you have problems of your own do you feel you could enjoy life more by becoming a more helpful neighbour?
21. If so, do you think you can offer some informal personal help?
22. Are you caring or helping care for a child under the age of 5?
23. Do you sometimes feel you need help?
24. Although most people want to volunteer to help their community, they worry about becoming over committed.So we are developing a new form of ‘drop in’ volunteering, which will only involve you voting or offering ideas about our projects on line, whenever you can spare the time. Please tick which of our current projects interest you

25. What is your email address?
26a. What is your phone number?
26b. What is your mobile number?
27. Are you happy for One Norbiton to contact you by email or phone?
28. What is your ethnic group?
A White

B Mixed

C Asian or Asian British

D Black or Black British

E Chinese or other ethnic group
29. What is your religion or belief?
30. What is your sexual orientation?
Please enter any comments you would like to make