Contact Details
If you would like to be involved in the Older People’s Engagement Network or receive more information then please fill in your details below. Alternatively you contact the OPEN team 01782 207200 or email ese questions form part of our on-going monitoring of diversity and equal opportunities for older people living in Stoke-on-Trent. We will not pass your details onto any other organisation.
Name …………………………………………………
Address ………………………………………………………………………………………………………………
Postcode ………………………………………… Telephone………………………………………..
Email …………………………………………………..
Signature …………………………………….. Date …………………………
Equal Opportunities, Diversity and Monitoring Information
Are you?Male Female
Year you were born………………………………………..
How would you best describe your ethnicity?......
Do you consider yourself to have a disability?......
How do you want to be involved?
Please use this questionnaire if you would like to become involved in the Older People’s Engagement Network, or to receive up-to-date information about the project. Please tick which answers you agree with.
Part 1: Have you ever been involved in giving your views about services for older people living in Stoke-on-Trent?
yes YesNo
Part 2: I would like to be involved by:
Attending larger-scale, quarterly OPEN Forum meetings
Hearing about and taking part in consultationsat my usual lunch/social club
Hearing about and taking part in consultations by email
Completing questionnaires by post
Receiving a regular newsletter
Being a member of the OPEN Committee
Please suggest any other ways in which you would like to be involved:
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Part 3: What decisions would you like to be consulted about?
Council and Local Government Services
Health and Social Care Services
Changes in the Voluntary Sector
Please suggest any other services you would like to be consulted about:
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Part 4: How would you like to receive feedback?
Newsletter/Letter
Telephone/Text
Social Media Announcement
Please suggest any other ways you would like to receive feedback:
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Part 5:Who should we target to make services for older people better?
Council Officers
Service Providers
Voluntary Organisations
Residents and Local Community Groups
Please suggest any other parties we should be targeting
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