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The following information is required in order that we can follow up your compliments, comments or complaint.  This information will only be used to improve our services.

Notes on Questions 11-15 about Diversity

We are committed to equality for everyone. Please answer questions 11-15 to help us meet the changing needs of our customers. This will also enable us to comply with our obligations under current legislation. The information you give us will be used only for monitoring purposes.

1. I'd like to make a... Comment Compliment Complaint

2. The name of the service you would like to compliment, comment or complain about:

3. Please give details of your compliment, comment or complaint below. Try to include dates and all the main points.

4. If you have made a complaint, what do you think we should do to sort out the problem?

5. Have you already contacted us about your complaint? Yes No

6. If YES, when did you complain?

7. Please give the name of the person who dealt with your complaint

8. If you were given a reference number, please give it here

9. What did they do about your complaint?

10. Why are you unhappy with the answer you received?

11. (see Diversity note at top of page) Sex: Male Female

12. Marital Status: Married Not married

13. Age: under 19 20-29 30-39 40-49 50-59 60+

14. Ethnic Origin: White: English, Scottish, Welsh, Northern Irish, Irish (Republic of) White: Any other background White and Asian Asian or Indian Asian British: Pakistani Asian British: Bangladeshi Asian: other background Chinese

15. Ethnic group: Any other background (please state)

This form may be completed anonymously. However, please provide some contact details if you would like a reply.

Name:
Address/Organisation:
Postcode:
Email:
Telephone: