Paradigm Housing Group

CUSTOMER PROFILE QUESTIONNAIRE

1. ABOUT YOU Which of the following best describes you? Please tick the relevant circle: Title: Miss/Ms/Mrs/Mr/other First name Last name Address Tenant Leaseholder You Shared Owner Your partner

Postcode Home phone number (Please include the area code) Mobile phone number Work phone number (Please include the area code) Email address @ Name of emergency contact / next of kin Relationship to you e.g. relative, friend Emergency contact / next of kin phone number (Please include the area code) 2. ABOUT THE PEOPLE IN THE HOUSEHOLD Please list everyone living in your home. First name Last name M Male, F Female, T Transgender Date of birth DD MM YY You Your partner Person 3 Person 4 Person 5 Person 6 Person 7 Person 8 Gender Please Tick M F T Relationship to you Please specify @

3. NATIONALITY / ETHNICITY How would you describe the nationality of your household?

How would you describe the ethnicity of your household? Please tick the relevant circle. White Mixed White White and Black Caribbean White and Asian Any other, please state Asian Indian Bangladeshi Any other, please state Black Any other ethnic group, please specify Gypsy/Romany/ Irish Traveller Prefer not to say 4. RELIGIOUS BELIEF What is the main religious belief in your household? Please tick the relevant circle. Christian None Muslim Buddhist Prefer not to say Hindu Sikh Jewish Any other religion (please state) Please give details of how we can best support you. e.g. important festival dates, do you follow specific religious or cultural practices? Caribbean Any other, please state African Pakistani White and Black African

5. SEXUAL ORIENTATION Please tick the relevant circle. Heterosexual Bisexual Gay Lesbian Other Prefer not to say

6. DISABILITY / SUPPORT NEEDS Please tick the circle where applicable. You Blind / Partially sighted Deaf / Hearing impairment Mobility difficulties Mental health problems Speech impairment Learning difficulties Unable to read or write any language Alcohol related problem Drug related problem Leaving Care / Institution Other health issues If other please specify Your partner Other members of your household
Please state the name(s) of household

If you have ticked any of the boxes above, please provide us with details of the disability, so that we can tailor our services to better suit your needs:

Do you have a support worker or carer to assist you? Name Contact number Organisation Is any member(s) of the household registered as disabled? If yes, which member? Does any member(s) of the household use a wheelchair? If yes, which member? Please tick if your home has any of the following adaptations Stair lift Ramp Hand rails Through floor lift

Yes

No

If yes, please give their name, contact number and the organisation they work for, if appropriate.

Yes Yes

No No

Level-access shower

Other, please specify

7. COMMUNICATIONS Please tick the relevant circle. You Can you speak English? Yes No Yes If no, what is your preferred spoken language? Can you read English? Yes No Yes No Your partner No

Would you like our literature translated into another language? Yes No Telephone Letter Personal visit

If yes, what is your preferred written language?

How would you prefer us to communicate with you? Please tick the appropriate circles. For information on electronic communication options, e.g. email or text message, see section 13. When we provide services, do you or anyone in your household require any additional support? Please tick the appropriate circles. You Information provided in larger print Information provided in braille Information provided on audio tape Information provided through an interpreter (If yes, please specify the language) Access to a signer To be visited at home Extra time required to answer the door Extra time required to answer the phone Other support, e.g. help filling in forms, please specify Your partner Other members of your household

8. EMPLOYMENT STATUS Please tick the appropriate circles. Full-time work (30 hours or more per week) Part-time work (less than 30 hours per week) Government training or New Deal Looking for work Retired Not seeking work Full-time student / part-time student Unable to work because of long-term sickness or disability None of the above Prefer not to say

You

Your partner

9. FUTURE PLANS How likely are you to want to move from your current home in the near future? Please tick one circle. Very likely Fairly likely Fairly unlikely Very unlikely Not wanting to move If you are considering moving now or in the future, which description below would describe your next move. Please tick one circle only. To rent from Paradigm Housing To rent from another housing association To rent from Council / Local Authority To rent from private landlord To buy shared ownership (part rent, part buy) To buy own property (mortgage, buy outright) Other, please specify

Prefer not to say

10. CUSTOMER INVOLVEMENT Please tick the circle wherever applicable. I am interested in: Getting involved in the local neighbourhood and community; e.g. joining an estate walkabout or clean up. Shaping the way Paradigm delivers services; e.g. joining a group or forum to influence changes to the grounds maintenance or repairs service. Getting involved in strategic decision making; e.g. becoming a resident board member. Yes No Maybe

11. HOME CONTENTS INSURANCE Do you currently have home contents insurance? If no, are you happy for us to send you more information? Yes Yes No No

12. YOUR OWN TRANSPORTATION Do you or your household members have use of a motor vehicle? How many cars are kept at your household? Yes No

13. ELECTRONIC COMMUNICATIONS Do you have access to the internet at home? Do you have access to the internet at work? Would you like to receive information by email? If yes, please state your preferred email address @ Would you like to receive information by text messages? If yes, please state your preferred mobile number Information from Paradigm can only be sent to the person(s) named on the tenancy or leasehold agreement. I confirm I am happy to receive emails and/or text messages as detailed above from Paradigm Housing Group. Your signature Your full name 14. What is the most important thing you would like Paradigm to do to improve services for you? Yes No Yes Yes Yes No No No

15. I/we understand that this information will be held and may be used for the duration of my/our tenancy with Paradigm Housing Group for the purposes of matters relating to my/our tenancy/ leasehold agreement, or until such time as I/we withdraw consent to this information being used. Your signature Your full name Your partners signature Your partners full name Date Date

Thank you for taking the time to complete this questionnaire

Press here to goPleasetop of the Form and select theenvelope provided. top right corner to the return to us in the prepaid Submit button in the For official use only: 2009/10 System input date: Quality check: TNO/CSA assistance: System input ref: Tenant/leaseholder ref no:
Paradigm Housing Group Hundreds House, 24 London Road West, Amersham, Bucks HP7 0EZ Tel: 01494 830991 Fax: 01494 830785