What is your HOME CODE NUMBER?
1. Can you read and understand English?	Yes	No
2. If not, would you like help answering this questionnaire?	Yes	No
3. Do you need a translator?	Yes	No
4. Are you happy to be our consultant?	Yes	No
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	Male	Female
8. What year did you start living in Norbiton?
9. How many years do you expect to stay here?
10. Who owns your house?	Local Authority	Right to Buy Freeholder
	Right to Buy Freeholder	Owner Occupier
	Private Rented	Housing Association
	Other	Don't know or rather not say
11. How many generations live in your household?	1	2	3
12. What is your Employment Status?	Full Time Employed	Part Time Employed
	Self Employed	Retired
	Unemployed	Student
	Other	Don't know or rather not say
13. Do you often feel lonely?	Yes	No
If yes, whom can you rely on for support if things go wrong?	My spouse or partner	My Family
	My Friends	My Neighbours
	My Church	Voluntary Agencies
	Social Services	Others
14. Do you often feel worried or under a lot of stress?	Yes	No
If yes, what causes it (Please tick all answers that apply to you)?	Poor health or disability	Fear of attack by strangers
	Family problems e.g. divorce/separation	Refugee from my homeland
	Conflicts with neighbours	Debt
	Change in benefits	Addictions to alcohol etc
	Other
15. If in Debt are you borrowing money in an expensive way such as a payday loan?	Yes	No
16. Do you ever have to choose between paying for food or heating your home?	Yes	No
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?	Yes	No
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?	Yes	No
20. Even if you have problems of your own do you feel you could enjoy life more by becoming a more helpful neighbour?	Yes	No
21. If so, do you think you can offer some informal personal help?	Yes	No
22. Are you caring or helping care for a child under the age of 5?	Yes	No
23. Do you sometimes feel you need help?	Yes	No
24. We are starting up these activities. Please tick any you may be interested in	Community Rangers Neighbourhood Watch	Energy 'Switch & Save' Edemocracy
	OneNorbiton Task Force
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?	Yes	No
28. What is your ethnic group?
A White	British Irish	Any other White Please tell us
B Mixed	White-Black Caribbean White-Black African	White-Asian Any other mixed Please tell us
C Asian or Asian British	Indian Pakistani	Bangladeshi Tamil
	Korean Any other Asian Please tell us
D Black or Black British	Caribbean African	Any other Black Please tell us
E Chinese or other ethnic group	Chinese	Any other background Please tell us
29. What is your religion or belief?	Christian	Buddhist
	Hindu	Sikh
	Jewish	Muslim
	Atheist	Agnostic
	Other - Please tell us
30. What is your sexual orientation?	Heterosexual (Man and Woman)	Lesbian
	Gay	Bisexual
	Other - Please tell us
Please enter any comments you would like to make