No

Question

Response (see footnote at the end of the questions)

1

At the last local government election, did you stand for election to a:

(please tick as appropriate)

·     County or County Borough Council

·     Community or Town Council

2

What is your status following the local election?

(please tick as appropriate)

·     Councillor -

County or County Borough

·     Councillor -

Community or Town Council

·     Unelected

3

In the local government election, which party, if any, were you representing?

(please tick as appropriate)

·     Independent

·     Plaid Cymru

·     Welsh Conservative Party

·     Welsh Labour Party

·     Welsh Liberal Democrats

·     Other (please specify)

4

Have you stood for election to a council in the past? (please tick as appropriate)

·     Yes (County or County Borough Council)

·     Yes (Community or Town Council)

·     No

5

Have you served as a councillor in the past? (please tick as appropriate)

·     Yes (County or County Borough Council)

·     Yes (Community or Town Council)

·     No

6

If yes, how many years in total have you served as a councillor?  Please include all periods of office that you have served as a councillor

·     Years as a county or county borough councillor

·     Years as a community or  town councillor

7

Are you:

(please tick as appropriate)

·     Male

·     Female

8

What age band were you in on your last birthday? (please tick as appropriate)

·         18-24 years

·         25-29 years

·         30-34 years

·         35-39 years

·         40-44 years

·         45-49 years

·         50-54 years

·         55-59 years

·         60-64 years

·     65 -69 years

·     70-74 years

·     75-79 years

·     80 years or over

9

What is your ethnic group?

(please tick as appropriate)

A. White

·     Welsh/English/ Scottish/ Northern Irish/British

·     Irish

·     Gypsy or Irish Traveller

·     Any other White background, write in

B. Mixed/multiple ethic groups

·     White and Black Caribbean

·     White and Black African

·     White and Asian

·     Any other Mixed/multiple ethnic background, write in

C. Asian/Asian British

·      Indian

·     Pakistani

·     Bangladeshi

·     Chinese

·     Any other Asian background, write in

D. Black/African/ Caribbean/Black British

·     African

·     Caribbean

·     Any other Black/African/ Caribbean background, write in

E. Other ethnic group

·     Arab

·     Any other ethnic group, write in

10

What is your religion?

·     No religion

·     Christian (all denominations)

·     Buddhist

·     Hindu

·     Jewish

·     Muslim

·     Sikh

·     Any other religion, write in

11

Do you consider yourself to be:

(please tick as appropriate)

·     Heterosexual or straight

·     Gay or lesbian

·     Bisexual

·     Other

12

What is your employment status?

(please tick as appropriate)

·     Self employed

·     In full time employment

·     In part-time employment

·     Unemployed

·     Retired

·     On maternity leave

·     Looking after family or home

·     Full-time student

·     Long term sick or disabled

·     On a government training scheme

·     Unpaid worker in family business

·     Unpaid carer

·     Doing something else  (please specify

13

What category best describes your current or most recent employment sector?

(please tick as appropriate)

·     Local government

·     Central government

·     NHS

·     Education

·     Other public sector

·     Private sector

·     Voluntary sector

·     Other (please specify)

14

If your status is employed, which category best describes your type of employment?

·     Managerial or executive

·     Professional or technical

·     Lecturer, teacher or researcher

·     Administrative, clerical secretarial or sales

·     Manual or craft

15

Do you have parental responsibility for a child aged 16 or under ?

(please tick as appropriate)

·     Yes

·     No

16

Have you given unpaid help to any of these types of groups or organisations at any time in the last 12 months?

For example as a volunteer, trustee or board member

(please tick all that apply)

·     Children’s education/ schools

·     Youth/children’s activities (outside school)

·     Education for adults

·     Sports or exercise (e.g. coaching)

·     Religious or faith based group

·     Gender group

·     Sexuality group

·     Political party

·     Health, disability or social welfare group

·     The elderly

·     First Aid

·     Environment group

·     Animal welfare group

·     Justice and Human Rights

·     Community or neighbourhood group

·     Citizens’ group

·     Social club

·     Trade Union

·     Other (please specify)

·     None

17

What is your highest education qualification?

(please tick as appropriate)

·         None

·     ‘O’ level, GCSE, CSE, NVQ 1/2 or equivalent

·     ‘A’ level, NVQ 3 or equivalent

·     NVQ level 4 or equivalent

·          Foundation or Ordinary degree

·          NVQ level 5

·         HND and HNC

·         Honours Degree

·         Master/Postgraduate qualification

·     Professional qualification (e.g. accountancy)

18

How is your physical  health in general?

(please tick as appropriate)

·     Very good

·     Good

·     Fair

·     Poor

·     Very Poor

19

How is your mental health in general?

(please tick as appropriate)

·         Very Good

·     Good

·     Fair

·     Poor

·     Very Poor

20

 Do you consider yourself to be a disabled person? (please tick as appropriate)

·     Yes

·     No

If so, do you have a:

Physical impairment

Sensory impairment

Learning disability

Mental health issue

Long term health condition

Other (please state)

21

If yes, does this illness or disability limit your activities in any way?

(please tick as appropriate)

·     Yes

·     No

22

Can you understand, speak, read or write Welsh?

(please tick all that apply)

·     Understand spoken Welsh

·     Speak Welsh

·     Read Welsh

·     Write Welsh

·     None of the above

23

What is your main language?

(please tick all that apply)

·     English

·     Welsh

·     Other, write in (including British Sign Language)