Our

 Ref:         COMMUNITY  SURVEY  2010  

 
About  You          Please  tick  or  circle  the  relevant  answers  
 
Gender   :         Male               Female  
 
Age:     Under  18  /  18-­‐29  /  30-­‐39  /  40-­‐49  /  50-­‐59  /  60-­‐69  /  70+  
 
Marital  Status:      Single/  Married/  Widowed  /Separated/  Divorced/Living  with  partner  
 

Your  Household:  How  many  people  in  your  household  fall  into  each  of  these  age  ranges?  
(excluding  yourself)  
 
0-­‐2   3-­‐4   5-­‐11   12-­‐17   18-­‐29   30-­‐39   40-­‐49   50-­‐59   60-­‐69   70+  
                   
 

Ethnic  Background:    Please  tick  which  description  best  fits  you.  

 
White  /  British     Black  or  Black  :  Caribbean    
Other  White  Background     Black  or  Black  African    
Mixed:  White  and  Black  Caribbean     Asian  or  Asian  British  :  Indian    
Mixed:  White  and  Black  African     Asian  or  Asian  British  :  Bangladeshi    
Chinese     Asian  or  Asian  British  :  Pakistani    
Other  (  please  state)        
 

Employment:  What  is  your  current  employment  status?  Please  tick  the  appropriate  box.  
 
Unemployed   Student   Currently  employed   Retired   Other  (  please  state)  
         
 

About  your  local  community  

 
How  long  have  your  lived  in  the  Kingsholm/  Wotton  area?  
___________________________________________________________________________________  
 
What  is  the  best  thing  about  living  in  Kingsholm/  Wotton?    
Please  rate  these  following  areas,  from  one  to  seven,  in  order  of  preference,  (1)  being  the  best  
and  (7)  being  the  least.  
 
Shopping     Facilities     Facilities  for     Community  Services    e.g     Location   Transport   Recreation  
Facilities   for  families   the  disabled   Police,  Community      
Centre,    Doctors  ,  etc..  
             
 
Other  (please  specify)    
______________________________________________________________________________________________________  
What  is  the  worst  thing  about  living  in  Kingsholm/wotton?  
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________  
 
What  do  you  perceive  the  local  needs  of  the  community  to  be?  
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________  
 
Issues  of  concern:  what  do  you  feel  are  the  main  issues  facing  this  community  to  be?    
Please  tick  the  appropriate  boxes.  
 
Issue  of  concern   Strongly   Agree   No  opinion   Disagree   Strongly  
agree   disagree  
Anti  social  behaviour            
Isolation            
Crime            
Community  safety            
Drugs            
Teenage  pregnancies            
Stress            
Unemployment            
Other  (please  state)  __________________________________________________________________________________  
_________________________________________________________________________________________________________  
 
Changes:  What  positive  changes  would  you  like  to  see  in  the  community?  
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________  
If  you  have  one  or  more  young  people  in  your  household  aged  18  or  under  please  ask  them  to  
say  what  improvements  they  would    like  to  see?  
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________  
 
Services  for  your  community    
 
Involvement:    Do  you  or  any  members  of  your  household  belong  to  any  local  groups?  
 
Yes                                                     No  
 
If  Yes,  which  ones?  _______________________________________________________________________  
Services:    In  your  local  community,  would  you  use  any  of  the  following  services?  (please  tick)  
 
SERVICES                      Definitely                      Maybe                                Never  
Coffee  bar/  Café        
Social  Activities  e.g.        
Cinema,  bingo,  etc  
Pregnancy  Crisis  support        
Activities  for  under  4’s        
Activities  for  5-­11’s        
Activities  for  11-­18’s        
Activities  for  over  50’s        
Education  support.  E.g.        
Homework  club  
Advice  Centre        
Community  Info  Centre        
Debt  Counseling        
Befrienders  Scheme        
Counselling  for  drug  and          
alcohol  abuse  
Housing  Benefit  Advice        
Stress  Management  Class        
Parenting  Support        
Workshops  on  health        
Related  issues  
Counselling  and  emotional        
 support  
Evening  class  e.e.  learn  a          
Language,  cookery,  etc  
Marriage  Support        
Learning  English  as  a          
Foreign  language    
Local  Church  Activities        
 

Does  anyone  in  your  household  have  a  disability?  

Yes                           No  
 
If  yes,  what  facilities/  groups  currently  support  them?      _________________________________________  
__________________________________________________________________________________________________________
What  services  would  they  benefit  from?    ___________________________________________________________  
__________________________________________________________________________________________________________  
Thank  you  for  taking  the  time  to  complete  this  questionnaire.  
 

To  enter  the  free  prize  draw,  £150  in  Asda  shopping  vouchers,  please  provide  us  with  
your  name  and  address  (  this  information  will  be  kept  confidential).                  Prize  draw  deadline  12  Dec  2010   th

 
Name:  
Address:  
 
             Please    Tick  box                          if  you  would  like  to  be  informed  of  ‘City  Church’  Activities.