Customer Survey Question Title * 1. Name OK Question Title * 2. Address OK Question Title * 3. Date of Birth Date: Date OK Question Title * 4. Gender Male Female Other OK Question Title * 5. Please provide your tenancy start date: Date: Date OK Question Title * 6. How many bedrooms does your home have? Studio 1 2 3 4 5 6 OK Question Title * 7. Landline Phone Number OK Question Title * 8. Mobile Number OK Question Title * 9. Email Address OK Question Title * 10. Household Income Per Year Under £10k £50k + Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 11. Are You Currently Employed: Full time Part time Retired Student Unemployed OK Question Title * 12. What benefits do you receive, if any? Universal Credit Housing benefit Jobseeker's allowance Disability living allowance Employment support allowance Income support Working tax credits Child tax credits Incapacity benefit Child benefit Carer's allowance Discretionary housing payments Pension credits Other (please specify) OK Question Title * 13. Verification document provided (please email to customer.services@coophomes.coop): Passport Driving Licence Other (please specify) OK Question Title * 14. What is your preferred language? OK Question Title * 15. What is the ethnic origin of the lead tenant? White British White Irish White other (please specify) Black British Black African Black Caribbean Black other (please specify) Asian British Asian Bangladeshi Asian Indian Asian Pakistani Asian other (please specify) Chinese Mixed - white and black Caribbean Mixed - white and black African Mixed - white and Asian Any other mixed background (please specify) Other ethnic group If you selected an 'other' option, please specify. OK Question Title * 16. Please provide details of other members of the household. Household member one: Surname First Name Date of Birth Relationship to tenant Gender Occupation status OK Question Title * 17. Details of household member two: Surname First Name Date of Birth Relationship to tenant Gender Occupation status OK Question Title * 18. Details of household member three: Surname First Name Date of Birth Relationship to tenant Gender Occupation status OK Question Title * 19. Please provide details of any other household members: OK Question Title * 20. Do you or any member of your family have a disability? (please specify below) Name: Nature of Disability: If you have a carer, please provide their name and contact details in case of an emergency: OK Question Title * 21. Do you have easy and regular access to the internet? Yes No OK Question Title * 22. If no, would you like help to get online? Yes No Maybe OK Question Title * 23. Are you signed up to MyTenancy, your online account with Co-op Homes which enables you to manage your tenancy and book repairs online? Yes No OK Question Title * 24. What would make our website more useful? OK Question Title * 25. Have you heard about our texting service? Yes No OK Question Title * 26. If you have used the texting service, what did you like/dislike? OK Thank you for taking part in this survey! Once you click 'done', you will be entered into our prize draw to win £50 in Love2Shop vouchers. OK Please note, this survey is strictly confidential and Co-op Homes will not share the details you provide with any third party. OK Question Title * 27. Is there anything you feel that Co-op Homes could do to improve our service to you? OK DONE
