Our customer profiling survey

The more we know about you, the more we can offer a service that suits your needs. It’s why we carry out our survey every year, to gather a few simple facts. These facts help us to provide a better, fairer service.

So please help us to make a better home for you by filling in as many details as you can. Then simply send in your form. We’ll even enter every completed form into a prize draw.

Please remember: only one entry per household.

Surname* First name* House/Flat number* Road/Court* Area Postcode help Daytime phone number (if none, put 'none') Email address

Ethnicity

Please tell us your ethnic background.

British Irish other Other white background (please state)

Mixed

white and black Caribbean white and black African white and Asian other mixed background (please state)

Asian or Asian British

Indian Pakistani Bangladeshi (please state)

Black or black British

African Caribbean Any other black background (please state)

Other ethnic background

Chinese Vietnamese Gypsy/Traveller Any other ethnic background

Other ethnic background

(please state)

Do you consider yourself to be a refugee?

Yes No

Gender

male female Other gender identity (please state)

Sexuality

heterosexual/straight gay man gay woman/lesbian bisexual rather not say

Sexuality

other (please state)

Religion/Belief

Christian Buddhist Hindu

Religion/Belief

Christian Buddhist Hindu Muslim Jewish Sikh None Other (please state)

Do you consider yourself to have a disability?

Yes No

If 'Yes' please tell us about the nature of your disability, so we can ensure our service is fair and accessible:

physical impairment hearing impairment visual impairment (that is not corrected by glasses or contact lenses) speech impairment severe disfigurement mental health problems learning disability learning difficulties or literacy/numeracy needs

Has your home been adapted to make it more suitable for a disabled person to live there? - for example ramps, hand-rails or a stairlift. (Answer 'yes' if it has adaptations, even if there isn't a disabled person in your home.)

Yes No If 'Yes' what adaptations are there?

Communication needs

Please tell us if you think we need to consider your individual needs when we communicate with you.

When we write to you If you have difficulty reading English, or you would like written information in another way, please tell us how you would like it.

Braille in large print on a CD I would like it sent in my language (please put the language here) I would like it sent to someone else (eg family member, carer). Please put their name and address here:

When we phone you Would you like us to use:

typetalk an interpreter

(If no one in your house speaks English, we can get an interpreter to translate the call)

If you need an interpreter, which language do you speak? or would you prefer to be contacted in another way?

When we visit you, or talk with you face-to-face, is there anything we should know?

I need a British Sign Language (BSL) interpreter to be there I need an interpreter who speaks my language. (please say which language) I would like to know when you are coming so I can have someone else there with me. I would like you to knock loudly and give me time to get to the door I would like you to use an agreed password (please tell us what) Other (please tell say what)

Thank you for your answers. You may want to check them before you send the form.

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Data Protection

The information you supply on this form will be sent to Parkway Green Housing Trust. It will only be used to process your request for information or the service(s) described on this page. Any details you supply will be treated confidentially and will only be used in direct relation to work needed to carry out your request.