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Tenancy audit
Consent for storing submitted data
Yes, I give permission to store and process my data
Staff member completing form
Property address
Tenant title
Miss
Ms
Mrs
Mr
Full name
Date of birth
National Insurance Number
Gender
Language
Religion
Sexual Orientation
Ethnic background
White British
White Irish
White Other
Mixed White and Black Caribbean
MIxed White and Black African
Mixed White and Asian
Mixed Other
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian or Asian British Other
Black or Black British Caribbean
Black or Black British African
Black or Black British Other
Chinese
Gypsy, Roma or Traveller
Other
Prefer not to say
Telephone number
Email address
Is there another tenant to add?
Yes
No
Tenant 2 Title
Miss
Ms
Mrs
Mr
Full name - Tenant 2
Date of birth - Tenant 2
National Insurance Number - Tenant 2
Gender - Tenant 2
Male
Female
Other
Language - Tenant 2
Religion - Tenant 2
Ethnic background - Tenant 2
White British
White Irish
White Other
Mixed White and Black Caribbean
MIxed White and Black African
Mixed White and Asian
Mixed Other
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian or Asian British Other
Black or Black British Caribbean
Black or Black British African
Black or Black British Other
Chinese
Gypsy, Roma or Traveller
Other
Prefer not to say
Sexual Orientation - Tenant 2
Telephone number - Tenant 2
Email address - Tenant 2
Contact preference
Phone
Email
Choose a security password
Are there any other residents living in this home?
Yes
No
Resident 3 Title
Miss
Ms
Mrs
Mr
Resident 3 - Full name
Resident 3 - Date of birth
Resident 3 - National Insurance Number
Resident 3 - Gender
Male
Female
Other
Ethnic background - Resident 3
White British
White Irish
White Other
Mixed White and Black Caribbean
MIxed White and Black African
Mixed White and Asian
Mixed Other
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian or Asian British Other
Black or Black British Caribbean
Black or Black British African
Black or Black British Other
Chinese
Gypsy, Roma or Traveller
Other
Prefer not to say
Resident 3 - Relationship to tenant 1
Are there any more residents?
Yes
No
Resident 4 Title
Miss
Ms
Mrs
Mr
Resident 4 - Full name
Resident 4 - Date of birth
Resident 4 - National Insurance Number
Resident 4 - Gender
Male
Female
Other
Ethnic background - Resident 4
White British
White Irish
White Other
Mixed White and Black Caribbean
MIxed White and Black African
Mixed White and Asian
Mixed Other
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian or Asian British Other
Black or Black British Caribbean
Black or Black British African
Black or Black British Other
Chinese
Gypsy, Roma or Traveller
Other
Prefer not to say
Resident 4 - Relationship to tenant 1
Are there any more residents?
Yes
No
Resident 5 Title
Miss
Ms
Mrs
Mr
Resident 5 - Full name
Resident 5 - Date of birth
Resident 5 - National Insurance Number
Resident 5 - Gender
Male
Female
Other
Ethnic background - Resident 5
White British
White Irish
White Other
Mixed White and Black Caribbean
MIxed White and Black African
Mixed White and Asian
Mixed Other
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian or Asian British Other
Black or Black British Caribbean
Black or Black British African
Black or Black British Other
Chinese
Gypsy, Roma or Traveller
Other
Prefer not to say
Resident 5 - Relationship to tenant 1
Are there any more residents?
Yes
No
Resident 6 Title
Miss
Ms
Mrs
Mr
Resident 6 - Full name
Resident 6 - Date of birth
Resident 6 - National Insurance Number
Resident 6 - Gender
Male
Female
Other
Ethnic background - Resident 6
White British
White Irish
White Other
Mixed White and Black Caribbean
MIxed White and Black African
Mixed White and Asian
Mixed Other
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian or Asian British Other
Black or Black British Caribbean
Black or Black British African
Black or Black British Other
Chinese
Gypsy, Roma or Traveller
Other
Prefer not to say
Resident 6 - Relationship to tenant 1
Are there any more residents?
Yes
No
Tenant 1 - Do you consider yourself to be disabled?
Yes
No
Tenant 1 - please tick all that apply
Hearing impairment
Speech impairment
Physical disability or limited mobility
Use a wheelchair/mobility scooter
Long term illness or health condition
Learning disability or difficulty
Mental Health condition
Tenant 1 - Considering your disability, long term illness or health problem, will you need aids and adaptations in the future that you don’t currently have?
Yes
No
Tenant 1 - Please use this box to give us more details about your disabilities and what impact you think this has on the way we should deliver our services to you.
Tenant 2 - Do you consider yourself to be disabled?
Yes
No
Tenant 2 - please tick all that apply
Hearing impairment
Speech impairment
Physical disability or limited mobility
Use a wheelchair/mobility scooter
Long term illness or health condition
Learning disability or difficulty
Mental Health condition
Tenant 2 - Considering your disability, long term illness or health problem, will you need aids and adaptations in the future that you don’t currently have?
Yes
No
Tenant 2 - Please use this box to give us more details about your disabilities and what impact you think this has on the way we should deliver our services to you.
Resident 3 - Do you consider yourself to be disabled?
Yes
No
Resident 3 - please tick all that apply
Hearing impairment
Speech impairment
Physical disability or limited mobility
Use a wheelchair/mobility scooter
Long term illness or health condition
Learning disability or difficulty
Mental Health condition
Resident 3 - Considering your disability, long term illness or health problem, will you need aids and adaptations in the future that you don’t currently have?
Yes
No
Resident 3 - Please use this box to give us more details about your disabilities and what impact you think this has on the way we should deliver our services to you.
Resident 4 - Do you consider yourself to be disabled?
Yes
No
Resident 4 - please tick all that apply
Hearing impairment
Speech impairment
Physical disability or limited mobility
Use a wheelchair/mobility scooter
Long term illness or health condition
Learning disability or difficulty
Mental Health condition
Resident 4 - Considering your disability, long term illness or health problem, will you need aids and adaptations in the future that you don’t currently have?
Yes
No
Resident 4 - Please use this box to give us more details about your disabilities and what impact you think this has on the way we should deliver our services to you.
Resident 5 - Do you consider yourself to be disabled?
Yes
No
Resident 5 - please tick all that apply
Hearing impairment
Speech impairment
Physical disability or limited mobility
Use a wheelchair/mobility scooter
Long term illness or health condition
Learning disability or difficulty
Mental Health condition
Resident 5 - Considering your disability, long term illness or health problem, will you need aids and adaptations in the future that you don’t currently have?
Yes
No
Resident 5 - Please use this box to give us more details about your disabilities and what impact you think this has on the way we should deliver our services to you.
Resident 6 - Do you consider yourself to be disabled?
Yes
No
Resident 6 - please tick all that apply
Hearing impairment
Speech impairment
Physical disability or limited mobility
Use a wheelchair/mobility scooter
Long term illness or health condition
Learning disability or difficulty
Mental Health condition
Resident 6 - Considering your disability, long term illness or health problem, will you need aids and adaptations in the future that you don’t currently have?
Yes
No
Resident 6 - Please use this box to give us more details about your disabilities and what impact you think this has on the way we should deliver our services to you.
Where practical, how would you prefer we communicate with you?
In writing
By email
By text message
By telephone
In person
When we contact you would any of the following help you?
Large print
Braille
Different Language
Speak loudly
Speak slowly
Do you have difficulty reading and/or writing?
Yes
No
Are there any special things we should know when we visit?
Knock loudly
Allow more time for the door to be answered
Use side/back door
Use a key from a key safe
You have a dog/dogs
Other
Visit - other details
Please tick for a digital signature confirmation.
Please tick for a digital signature confirmation.
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