We are looking for two people from South Gloucestershire and North Somerset to work with us to help us shape the strategic direction of the Citizens’ Panel by being a member of the Steering Group. You need not have a prior understanding of Citizens’ Panels or shaping surveys, however your views in steering and overseeing the development of the panel is important to us.

You will be asked to take part with others to offer your experiences and considered views in discussions with health and care professionals.

This questionnaire will close at midday on Monday 25th March, so please ensure your responses are submitted beforehand.

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* 1. Please tell us how your experiences can contribute to the group in around 400 words.

The next set of questions is to make sure we consider responses from those across our region and from all communities.

All the information you provide will be treated with confidentiality.

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* 2. In which of these areas do you live?

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* 3. What is your age group?

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* 4. Do you consider yourself to be a disabled person?

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* 5. If you answered 'Yes' to Q3:

It helps us to know whether we are including all people who see themselves as disabled or who have a long-term impairment or condition. Please tick the relevant impairment (disability) group below. You may tick more than one box if appropriate:

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* 6. What is your ethnic group?

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* 7. Do you have a religion or belief?

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* 8. If you answered 'yes' to Q11:

Are you...

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* 9. Are you:

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* 10. Which of the following best describes how you think of yourself?

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* 11. In order to be contacted about this opportunity, please provide your e-mail address (or another way of contacting you)

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