Stafford and Rural Homes

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We will recognise the diverse nature of our society and respond positively to it.

Having your Say

Comments, Compliments and Complaints

PLEASE PRESS THE "TAB" KEY TO MOVE BETWEEN FIELDS.

Click to see the Comments, Compliments and Complaints policy

About you

Name

Address

Tel No

Email Address

Are you a:

tenant	leaseholder
housing applicant	partner organisation
other (please specify)

Are you making contact on behalf of anyone else?

Yes No

If so, are they:

tenant	leaseholder
housing applicant	partner organisation
other (please specify)

What is the person's name

Address

Please ensure you have obtained the person's signature to enable us to share information with you. If the signature is not obtained we will write directly to the person concerned.

Details of your comment, compliment or complaint

Are you making a:

Compliment

Comment

Complaint

Please give full details

What do you expect to see happen next?

Have you contacted S&RH previously on this subject?

Yes No

Who did you contact?

Monitoring Information

The information used on this form is strictly confidential; it is used to ensure that our services are delivered fairly to everyone in the community.

Gender/Age

Please tick the correct box and enter your date of birth

	Tenant 1	Tenant 2
Female
Male
Transgendered m to f
Transgendered f to m
Date of birth (DD/MM/YYYY)

I prefer not to answer

Disability

Do you or a member of your household have a long term disability (over 6 months) that prevents you from carrying out normal day to day activities?

Yes No

If yes, is your disibility (please tick)

Sight loss

Blind

Hearing loss

Deaf

Deaf and without speech

Learning difficulties

Mobility problems

Wheelchair user / mobility scooter user indoor and outdoor

Wheelchair user / mobility scooter user - outdoor only

Substance misuse

Mental health issues

Chronic illness

Other (please specify)

I prefer not to answer

Religion

Please tick the appropriate box

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

I prefer not to answer

Your background

Please tell us your ethnic background by ticking the appropriate box from sections A to E below.

A. White

British
Irish
Other

B. Mixed

White and Asian
White and Black African
White and Black Caribbean
White and Asian
Other

C. Black or Black British

African
Caribbean
Other

D. Chinese or other ethnic group

Chinese
Other

I prefer not to answer

If English is not your first language please specify the language that you use

Sexuality

Please tick the appropriate box below to indicate your sexuality. You may be uncomfortable with answering this, in which case you can leave it blank. But if you do answer it we will be able to check more accurately that everyone is treated fairly. Remember this information is confidential.