Getting to know you better…
helping us to help you
If you need help filling out the survey, have any questions, need the survey in Welsh, another language or
format, please contact our customer line on 0800 111 4242. Os oes angen help arnoch i lenwi'r arolwg, ateb
unrhyw gwestiynau, angen yr arolwg yn Gymraeg neu iaith neu fformat arall, cysylltwch â'n llinell cwsmeriaid
ar 0800 111 4242.
1 Your contact details
Your address: __________________________________________________________________
Your home phone no. ________________________________
Your mobile: ______________________________
Your email: _______________________________
2 You and your household
Full name
Date of birth
(dd/mm/yyyy)
Sex
(Male/Female)
Marital status
You – tenant 1
Tenant 2
3 What is your preferred language when communicating with us?
English ☐ Welsh ☐ Nepalese ☐ Polish ☐ Tagalog/Filipino ☐ Bengali ☐ Chinese ☐
Panjabi ☐ Thai ☐ French ☐ Italian ☐ Turkish ☐ British Sign Language ☐ Other __________
4 When dealing with us, would you benefit from any of the following? (Please tick all that apply)
☐Large print
☐Hearing Loop
☐Braille
☐Information on CD
☐Sign Language ☐Translation
☐Support with reading ☐Support with writing
☐Other – please specify _______________________________________
☐Prefer not to say
5 Do you have access to the internet?
Yes
☐
No ☐
6 Do you or the other member of your household have a disability or medical condition?
(Please answer questions 7 & 8. If no, please go to question 9)
Yes ☐
No ☐
Prefer not to say ☐
7 It helps us to know whether we are reaching all disabled people. Which of the following best
describes the condition or disability? (Please tick all that apply for each member of the
household)
Tenant 1
Tenant 2
Deafness or hearing impairment
Blindness or vision impairment
Physical disability/ impairment or mobility issues
Learning disability
Learning difficulty, such as dyslexia
Mental health condition, such as depression or schizophrenia
Social/ communication impairment such as Asperger's syndrome/other autistic
spectrum disorder
Long term health condition, such as chronic heart disease or epilepsy
8 Are the day-to-day activities limited because of the medical condition or disability which has
lasted, or is expected to last at least 12 months? (Please tick one for each member of your
household)
Tenant 1
Yes, limited a lot
Yes, limited a little
No
Prefer not to say
Tenant 2
9 Which of the following best describes your ethnic origin? (Please tick one for each member
of the household)
Tenant 1
Tenant 2
Welsh/English/Scottish/Northern Irish/British
Irish
Gypsy or Irish Traveller
White and Black Caribbean
White and Black African
White and Asian
Indian
Pakistani
Bangladeshi
Chinese
African
Caribbean
Arab
Any other ethnic group, please describe
Prefer not to say
10 Which of the following best describes your religion or belief (Please tick one for each
member of the household)
Tenant 1
Tenant 2
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Any other religion or belief, please describe
No religion
Prefer not to say
11 Which of the following best describes your sexual orientation? (Please tick one for each
member of the household)
Tenant 1
Tenant 2
Lesbian/Gay Woman
Gay Man
Bisexual
Heterosexual
Don’t know
Prefer not to say
12 Which of the following best describes your gender identity? (Please tick one each member
of the household)
Tenant 1
Tenant 2
Same as assigned at birth
Different to that assigned at birth
Not known
Prefer not to say
Thank you for taking the time to complete the survey. Please return to Bron Afon Community
Housing in the pre-paid envelope provided, or drop it into us at our office in William Brown Close.
Return your completed form by 31 October 2016 and be automatically entered into our prize draw you could win £100 in vouchers.
And just before you go…. Did you know that Bron Afon has a tenant portal where you can
check your rent balance and much more? Find out more by visiting
https://www.bronafon.org.uk/my-account/