Interested in Having Your Say on the Future of West Lothian?

West Lothian is recruiting new members to its Citizens’ Panel

The West Lothian Citizens’ Panel was set up as a way for local people to give their opinion on services in their local area and influence decision makers. The Panel is made up of all different sorts of people of different ages and backgrounds. The only qualification you need to have to join is to be a resident of West Lothian. Becoming a member is your chance to have your say about the Council and its Partner’s services, plans and policies. As a Panel member, you will be sent a survey on the quality of life in West Lothian which should take no more than 20 minutes of your time to complete. From time to time, Panel members may also be invited to take part in group discussions or may receive questionnaires from specific Council services or Partner agencies. Your participation is entirely voluntary and you can decide to participate or not in each survey. It is up to you if you want to take part. Your views will always be kept confidential.

Why do we need to collect personal information? The information we ask for is used to help us make sure that we have representation on the Panel from all types of individuals across West Lothian and will be used to analyse your responses to future surveys.

Step 1

	To confirm that you wish to join the West Lothian Citizens' Panel, please tick the YES box
	YES ! I wish to join the Citizens' Panel to have my say

Step 2 - Your Contact Details

	Please confirm your personal details in the space provided:
	Name
	House Number/ Name
	Street
	Town
	Postcode
	Telephone Number
	Mobile Number
	Email Address

Step 3 - Information about You and Your Household

In order to analyse your answers in future surveys, we need to ask some questions about you and your household. All the information you send us is strictly confidential and will be processed and held in accordance with the principles of the Data Protection Act (1998). The information will be used only for statistical and research purposes and no individuals will be identified when we report our findings. We will not pass any information on about you as an individual to any other organisation, without your express permission. Please complete the following questions about you and your household.

	Q1 Are you?
	Male		Female

	Q2 Your age group
	17-24		55-59
	25-34		60-64
	35-44		65-74
	45-54		75 and over

	Q3 How many people are in your household? (Type in number)
	Pre-school age children               (usually under 5 years old)
	Primary school age children         (usually 5-12 years old)
	Secondary school age children
	Adults (including you)
	Total

	Q4 Is the house you live in?
	Privately owned by you or a member of your family
	Rented from the Council
	Rented from a Housing Association or Housing Co-operative
	Rented from private landlord or letting agency
	Residential care or nursing home
	Other

	If other, please specify

	Q5 How long have you been living in West Lothian?
	Less than 2 years		11-20 years
	2-5 years		More than 20 years
	6-10 years

	Q6 What is your employment status? (Please select one only)
	Employed full time		Retired
	Employed part time		Student
	Self employed		Not working due to ill health or disability
	Government sponsored training scheme		Looking after home and/ or family
	Unemployed and seeking work		Other

	If other, please specify

	Q7 If you said you are employed, are you an employee of any of the following agencies?
	West Lothian Council		Lothian and Borders Fire and Rescue
	NHS Lothian		Scottish Enterprise
	Lothian and Borders Police		None of these

	Q8 If you said you were employed, do you?
	Work in West Lothian		Work outwith West Lothian

	Q9 Which of the following options best describes how you think of yourself?
	Bi-sexual		Heterosexual/ straight
	Gay man		Other
	Gay woman/ lesbian		Prefer not to say

	Q10 What religion, religious domination or body do you belong to?
	Buddhist		Church of Scotland
	Hindu		Jewish
	Muslim		No religion
	Other Christian		Pagan
	Roman Catholic		Sikh
	Other		Prefer not to say

	Q11 Do you consider yourself to have a disability?
	Yes, affecting hearing		Yes, affecting mobility
	Yes, affecting vision		Yes, affecting learning/ understanding
	Yes, other		No

	Q12 What is your ethnic group?
	Scottish
	English
	Welsh
	Northern Irish
	British
	Irish
	Gypsy Traveller
	Polish
	Any other white ethnic group
	Any mixed or multiple ethnic groups
	Pakistani, Pakistani Scottish or Pakistani British
	Indian, Indian Scottish or Indian British
	Bangladeshi, Bangladeshi Scottish or Bangladeshi British
	Chinese, Chinese Scottish or Chinese British
	Other Asian ethnicity
	African, African Scottish or African British
	Caribbean, Caribbean Scottish or Caribbean British
	Black, Black Scottish or Black British
	Other African or Black ethnicity
	Arab
	Other ethnicity

	Any other white ethnic group ...please specify

	Any other mixed or multiple ethnic group ...please specify

	Other Asian ethnic group ...please specify

	Other African or Black ethnic group...please specify

	Other ethnic group...please specify

	Q13 In what format would you like to receive your West Lothian Panel questionnaire and newsletters?
	Paper through the post
	Electronic/ online via email/ the internet

If ticked electronic/ online option above, please make sure you have supplied your email address at the 'Your Contact Details' section.

Thank you very much for applying to join the West Lothian Citizens' Panel!