What is your HOME CODE NUMBER?
1. Can you read and understand English?
2. If not, would you like help answering this questionnaire?
3. Do you need a 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)?
15. If in Debt are you borrowing money in an expensive way such as a payday loan?
16. Do you ever have to choose between paying for food or heating your home?
17. We are lucky that a new Credit Union - 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 the changes in benefits allowance or bedroom tax will affect 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. We are starting up these activities. Please tick any you may be interested in
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