10. Which of the following best describes your sexual orientation?
Heterosexual / straight
Gay or lesbian
Bisexual
Prefer not to say
Other
.1 Gender
Female
Male
Prefer not to say
Other
1. Have you ever lived outside of your country for more than 3 years (consecutively)?
YES
NO
1RatioSetForchoiceTest
i1
i2
i3
1. What rank are you currently sailing as?
Captain
Chief Officer
Chief Engineer
Second Officer
Second Engineer
Third Officer
Third Engineer
Fourth Engineer
Deck Rating (non officers)
Engine Room Rating
Deck Cadet
Engine Cadet
Catering Department
Electrical Department
Other
.2 Age
18-24
25-34
35-44
45-44
55 or over
Prefer not to say
2. What type of vessel are you currently working on?
Bulk carriers
Container ships
Naval ships
Offshore ships
Passenger ships
Special purpose ships
Tanker ships (chemical / gas / oil)
.3 Ethnicity
Asian or Asian British
Black or Black British
Mixed
White
Other Ethnic Group
Prefer not to say
3. How long is your usual seafaring contract?
1 - 2 months in duration
2 - 3 months in duration
3 - 6 months in duration
6 - 9 months in duration
9 - 12 months in duration
12 months plus
Other
4-10 Participants
Yes
No
42. How old are you? (this will help us assess how inclusive we're being)
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
43. Which of the following best describes your gender? (this will help us assess how inclusive we are being)
Female
Male
Non-binary
Prefer not to say
Other
44. Is the gender you identify the same as that which was identified at birth? (this will help us assess how inclusive we are being)
Yes
No
Prefer not to say
45. Which of the following best describes your ethnicity? (this will help us assess how inclusive we are being)
White (includes British, Northern Irish, Irish, Gypsy, Irish Traveller, Roma or any other white background)
Mixed or multiple ethnic groups (includes White and Black Carribean, White and Black African, White and Asian or any other Mixed or Multiple background)
Asian or Asian British (includes Indian, Pakistani, Bangladeshi, Chinese or any other Asian background)
Black, Black British, Caribbean or African (includes Black British, Caribbean, African or any other Black background)
Other ethnic group (includes Arab or any other ethnic group)
Prefer not to say
46. Which of the following best describes your approximate household income per month? (this will help us understand how far CAL is reaching people facing social justice issues)
£1,000 or less
£1,001 to £2,000
£2,001 to £3,000
£3,001 to £5,000
£5,001 or more
Prefer not to say
47. Do you describe yourself as having a disability? (this will help us assess how inclusive we are being)
Yes
No
Prefer not to say
.4 Location (ordinarily do you principally work from...)
Office
Home
4. Which sex are you?
Male
Female
Prefer not to say
5. Is your gender the same as the sex you were registered at birth?
Yes
No
Prefer not to say
.5 Work status
Not been on furlough
Currently on furlough
Now working but previously on furlough
6. What is your nationality?
Afghan
Albanian
Algerian
American
Andorran
Angolan
Antiguans
Argentinean
Armenian
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Barbudans
Batswana
Belarusian
Belgian
Belizean
Beninese
Bhutanese
Bolivian
Bosnian
Brazilian
British
Bruneian
Bulgarian
Burkinabe
Burmese
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Central African
Chadian
Chilean
Chinese
Colombian
Comoran
Congolese
Costa Rican
Croatian
Cuban
Cypriot
Czech
Danish
Djibouti
Dominican
Dutch
East Timorese
Ecuadorean
Egyptian
Emirian
Equatorial Guinean
Eritrean
Estonian
Ethiopian
Fijian
Filipino
Finnish
French
Gabonese
Gambian
Georgian
German
Ghanaian
Greek
Grenadian
Guatemalan
Guinea-Bissauan
Guinean
Guyanese
Haitian
Herzegovinian
Honduran
Hungarian
I-Kiribati
Icelander
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakhstani
Kenyan
Kittian and Nevisian
Kuwaiti
Kyrgyz
Laotian
Latvian
Lebanese
Liberian
Libyan
Liechtensteiner
Lithuanian
Luxembourger
Macedonian
Malagasy
Malawian
Malaysian
Maldivian
Malian
Maltese
Marshallese
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monacan
Mongolian
Montenegrin
Moroccan
Mosotho
Motswana
Mozambican
Namibian
Nauruan
Nepalese
New Zealander
Ni-Vanuatu
Nicaraguan
Nigerian
Nigerien
North Korean
Northern Irish
Norwegian
Omani
Pakistani
Palauan
Panamanian
Papua New Guinean
Paraguayan
Peruvian
Polish
Portuguese
Qatari
Romanian
Russian
Rwandan
Saint Lucian
Salvadoran
Samoan
San Marinese
Sao Tomean
Saudi
Scottish
Senegalese
Serbian
Seychellois
Sierra Leonean
Singaporean
Slovakian
Slovenian
Solomon Islander
Somali
South African
South Korean
Spanish
Sri Lankan
Sudanese
Surinamer
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Togolese
Tongan
Trinidadian or Tobagonian
Tunisian
Turkish
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbekistani
Venezuelan
Vietnamese
Welsh
Yemenite
Zambian
Zimbabwean
Prefer not to say
Other
7. What is your ethnic group?
American Indian or Alaska Native
Asian
Australian Aboriginal
Black
Hispanic or Latinx
Middle Eastern or North African
Mixed/Multiple Ethnic Groups
Native Hawaiian or other Pacific Islander
White
Prefer not to say
Other
8. What is your religion or belief?
Buddhist
Christian
Hindu
Jewish
Muslim
No religion or belief / Atheist
Sikh
Prefer not to say
Other
9. What age category are you in?
16-24
25-34
35-44
45-54
55-64
65+
Prefer not to say
Ability to work with minimum support
1
2
3
4
5
Accessibility requirements
Quiet/ private space needed
Prefers to be seen by female colleague
Prefers to be seen by male colleauge
No preference
Hearing Loop
Translator/ interpreter
Needs acccessible space ( e.g. wheelchair/ push chair)
Other support needed
No additional support needed
Access to booster seat
Yes
No
Accommodation status
Living with family
Living in semi-independent accommodation
Live in placement
Live independently
Homeless
Living in custody (sentenced HMP/YOI)
Living in secure home
Living in remand
Accommodation status
Home Owner
Renting
Housing Trust
Temporary
Action plan in place?
Yes
No
Action Taken
ADR
APPEAL
BAIL AND BOND
CLIENT INTERVIEW
GUILTY PLEA & MITIGATION
PLEA BARGAINING
RECORDS REQUEST
SENTENCE REVIEW
SENTENCING
TRIAL PREPARATION
Activities interested in
Computers
Cooking
Dance
Football
Graffiti / Arts
Multi Sports
Music
Other
Pool
Table Tennis
Workshop/Discussions
Activity
After-school discipleship group
Amber Space
Annual Easter activities
Breakfast Club
Bring faith to Life with St Micheals School
Bubble Church
Church on Jarvis
Church Service
Coffee morning (now finished)
Confirmation Class
Crafty Church
Diddy disciples
Discipleship resources for Sunday services
Edible Garden space
Experience Christmas school’s activity
Experience Church Resources
Experience Resources with local primary schools and St Micheals Secondary school
Faith at home kits
Family Faith Sessions
Forest Church
Forest Church Exploration Day
Growing Young Leaders
Ignite Youth Group
LINKS activities with St Micheals School
Muddy Church
N/A currently
Occasional Office resources
Outdoor Church at St Giles
Parents Prayer group
Prayer Space
Prayer station – St Micheals Secondary school
Prayer station activity
Prayer stations with St Margaret’s CofE Primary school
Red space (Youth Led worshipping community)
Resource sharing
Safeguarding Training
Shine resources
Shustoke School - activities
St Barnabas Primary School activities
St Giles Youth Group
St Micheals school Centenary celebrations for St Giles
Sunday Youth Space (Amber to red space)
Volunteer Training Package
Youth service (through the youth band)
Activity for AM
Archery
Archery tag (Mojo)
Bird Box making
Board games (Chance & Counters)
Bouldering (Bloc)
Bouldering (Flash Point)
Boxing (Empire Fighting Chance)
Bristol Aquarium
Bristol Ferry
Bushcraft
Canoeing (All Aboard)
Caving
Cheddar Expedition (walking)
Climbing
Climbing (Red Point)
Clip & Climb (Bloc)
Crazy Climb (Red Point)
Cycle expedition (Bristol to Bath)
Cycle expedition (Long Ashton)
Cycle expedition (Pill tow path)
Cycle expedition (Strawberry Line)
Fishing (Chew Valley Lake)
Fishing (Jacklands)
Frisbee Golf
Geocaching (Harbourside)
Go Karting (Absolute Karting)
Go Karting (JDR)
Go Karting (M4 Karting)
Golf (Filton)
Golf (In Play Golf Centre)
Golf (Jungle Rumble)
Golf (Pirate Crazy Golf)
Golf (Tickenham Driving Range)
Gymnastics
High ropes (Mojo)
Ice Skating (Mall)
Jump Biking (Hillfields)
Jump Biking (Kingsway, Gloucester)
Jump Biking (Lawrence Weston)
Jump Biking (Patchway)
Jump Biking (Pump track near base)
Kayaking (All Aboard)
Lazer Quest (Lazer Fusion)
MTB (Ashton Court)
MTB (Forest of Dean)
MTB (Harbourside skills challenges & games)
MTB (Leigh Woods)
Museum - Aerospace
Museum - Bristol Museum
Museum - M-Shed
Museum - We The Curious
Nerf battle (Mojo)
Noah's Ark
Orienteering (Clifton Down)
Orienteering (Grenville Park)
Orienteering (Mendips)
Paddle boarding (All Aboard)
Photo challenge (Harbourside)
Pool/darts (All Stars sports bar)
Puxton Park
Rifle shooting
Sailing (All Aboard)
Sand Bay
Shop ( Rybrook specialist cars)
Shop (Flying Saucers pottery painting)
Shop (Fowlers motorcycles)
Skate park (Bradley Stoke)
Skate park (Campus)
Skate park (Filton)
Skate park (Hengrove)
Skate park (Horfield)
Skate park (Lawrence Weston)
Skate park (Rush)
Skate park (St George's)
Skiing
Slack lining
Snowboarding
SS Great Britain
St Werburgh's City Farm
Surfing (The Wave)
Table Tennis (Ping Pong parlour)
Team Building (Angry birds)
Team Building (Athletics)
Team building (Mojo)
Team Building (races)
Team Building (spider web)
Team Games (Spike ball etc)
Tracking
Trampline park (Air Hop)
Trampoline park (Freedog)
Trap Fall making
Watersports (Mendips)
Weston-Super-Mare
Weston-Super-Mare pier
Wild Place - Leap of Faith
Wilderness Project (allotments)
Windmill Hill City Farm
Zorb football (Mojo)"
Activity for PM
Archery
Archery tag (Mojo)
Bird Box making
Board games (Chance & Counters)
Bouldering (Bloc)
Bouldering (Flash Point)
Boxing (Empire Fighting Chance)
Bristol Aquarium
Bristol Ferry
Bushcraft
Canoeing (All Aboard)
Caving
Cheddar Expedition (walking)
Climbing
Climbing (Red Point)
Clip & Climb (Bloc)
Crazy Climb (Red Point)
Cycle expedition (Bristol to Bath)
Cycle expedition (Long Ashton)
Cycle expedition (Pill tow path)
Cycle expedition (Strawberry Line)
Fishing (Chew Valley Lake)
Fishing (Jacklands)
Frisbee Golf
Geocaching (Harbourside)
Go Karting (Absolute Karting)
Go Karting (JDR)
Go Karting (M4 Karting)
Golf (Filton)
Golf (In Play Golf Centre)
Golf (Jumgle Rumble)
Golf (Pirate Crazy Golf)
Golf (Tickenham Driving Range)
Gymnastics
High ropes (Mojo)
Ice Skating (Mall)
Jump Biking (Hillfields)
Jump Biking (Kingsway, Gloucester)
Jump Biking (Lawrence Weston)
Jump Biking (Patchway)
Jump Biking (Pump track near base)
Kayaking (All Aboard)
Lazer Quest (Lazer Fusion)
MTB (Ashton Court)
MTB (Forest of Dean)
MTB (Harbourside skills challenges & games)
MTB (Leigh Woods)
Museum - Aerospace
Museum - Bristol Museum
Museum - M-Shed
Museum - We The Curious
Nerf battle (Mojo)
Noah's Ark
Orienteering (Clifton Down)
Orienteering (Grenville Park)
Orienteering (Mendips)
Paddle boarding (All Aboard)
Photo challenge (Harbourside)
Pool/darts (All Stars sports bar)
Puxton Park
Rifle shooting
Sailing (All Aboard)
Sand Bay
Shop (Rybrook specialist cars)
Shop (Flying Saucers pottery painting)
Shop (Fowlers motorcycles)
Skate park (Bradley Stoke)
Skate park (Campus)
Skate park (Filton)
Skate park (Hengrove)
Skate park (Horfield)
Skate park (Lawrence Weston)
Skate park (Rush)
Skate park (St George's)
Skiing
Slack lining
Snowboarding
SS Great Britain
St Werburgh's City Farm
Surfing (The Wave)
Table Tennis (Ping Pong parlour)
Team Building (Angry birds)
Team Building (Athletics)
Team building (Mojo)
Team Building (races)
Team Building (spider web)
Team Games (Spike ball etc)
Tracking
Trampoline park (Air Hop)
Trampoline park (Freedog)
Trap Fall making
Watersports (Mendips)
Weston-Super-Mare
Weston-Super-Mare pier
Wild Place - Leap of Faith
Wilderness Project (allotments)
Windmill Hill City Farm
Zorb football (Mojo)
Activity Location
Blackburn
Bolton
Burnley
Bury
Manchester
Oldham
Other
Pendle
Preston
Rochdale
Rossendle
Activity Type
Ability
Blackbelt Warrior
Boost Fitness
Let's Learn
Senior Care
Stop Think Self Defence
Transform4Life
Volunteer Programme
YouthCan
Z Adventure
Address
English
French
German
Indian
Adopted/fostered
Yes - adopted
Yes - fostered
No
Adult Ethnic Group
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Other
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Other
Asian - Indian / British Indian
Asian - Pakistani / British Pakistani
Asian - Bangladeshi / British Bangladeshi
Asian - Chinese
Asian - Other
Black – African / African British
Black – Caribbean / Caribbean British
Black – Other
Arab
Any other ethnic group
Choose not to disclose
Adverse Childhood Experiences
Caregiver Substance Abuse
Incarceration of a caregiver or other close relative
Family breakdown
Domestic violence
Experience of abuse
Experience of neglect
Family mental health concerns
Affected by parental imprisonment?
None
Historic
Current
After coming to this training, do you feel part of a wider mission-team with other Christian sportspeople?
Not at all
Not much
A little
Quite a lot
Very much
Age
Under 13
Under 16
16-19
19+
Age
0-5
6-10
11-14
15-18
19-25
Age
Up to 19
20 - 25
26 - 35
36- 45
46 - 55
56 - 65
66 - 74
75 - 84
85 - 89
90 - 94
95 - 99
100+
Age
20 - 30
Age
0-16
16-25
25-49
50+
Age
Under 18
18 - 25
25 - 40
40+
Age:
14-16
16-18
Age: are you?
Less than 18
18-25
26-35
36-45
46-55
56-65
66-75
76-85
Over 86
Age at the start
9
10
11
12
Age at the start (Secondary)
11
12
13
14
15
16
17
18
Age Category
Adult
Youth
Age (dropdown list)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Age II
18-21
22-24
25+
Agency or Self Referral
Agency
Self Referral
Agency Type
Childrens Centre
School
Voluntary/Community
Faith
Housing Association
Statutory
Other
Age range
Below 25
25-30
30-40
40-50
50-60
Over 60
Age range
Under 18
18-24
25-34
35-44
45 above
Age Range
11 year olds
12 year olds
13 year olds
14 year olds
15 year olds
16 year olds
Age Range (Imported)
18 To 24
25 To 34
35 To 44
45 To 54
55 To 64
Age (standard)
Aged Under 10 Years Old
Aged 11-15 Years Old
Aged 16-17 Years Old
Aged 19-24 Years Old
Aged 25-30 Years Old
Aged 31-40 Years Old
Aged 41-50 Years Old
Aged 51-60 Years Old
Aged 61-70 Years Old
Aged 71-80 Years Old
Aged 81-90 Years Old
Aged 91-100 Years Old
Aged Over 101 Years Old
Age SubCategories
Age 0-16
16-18
18-25
Age (under 17 - over 60)
17 or younger
18-20
21-29
30-39
40-49
50-59
60 or older
A) I am in control of my life
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
A) I can always manage to solve difficult problems if I try hard enough.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Aim
Skills
Knowledge
Recruitment
Promotion
Networking
Fundraising
A) I/we are unable to afford food due to finances
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
A) I/we have are unable to afford food due to finances
Strongly Agree
Agree
Neither Agree/Disagree
Empty Answer Choice
Strongly Disagree
A) I/we have good levels of access to facilities and services in our local community
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
A) I/we regularly* eat five portions of fruit or vegetables each day
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Allergies to horses or other severe allergies e.g., wasps, nuts etc.
Yes
No
Allow bulk email
Yes
No
Allow contact by :
Email
Post
Phone
What's App messenger
Allow contact by other Social Media
Yes
No
Allow contact notes
Yes
No
Allow email
Yes
No
Allow post
Yes
No
Allow sms
Yes
No
All photos / videos that we take will show the person / group (back view not frontal). I give consent for Communities First Foundation to take these photos / videos to use on social media / marketing purposes:
Yes
No
Anime Series
Naruto
One Piece
Solo Leveling
Attack on Titan
Any additional needs?
Disability
Mental Heatlth
Learning Difficulties
Other
Any Allergies?
Yes
No
Any condition that makes it dangerous for the person to be active
Yes
No
Any disabilities (Imported)
Yes
No
Any medication or treatment required
Yes
No
Any other condition or medication side effects, that may make it dangerous for the person to participate in Equine Therapy, e.g. diabetes or heart conditions
Yes
No
Any other information about your wellbeing needs that you would like us to know?
Relationships
Bullying
Bereavement
Anxiety
Anger
General wellbeing
Self-esteem
Sleep disturbances
Sadness
Suicidal Thoughts
Confidence
Succeeding in school
Behaviour
Attendance at school
Other
Any person participating in our programme does so at their own risk. Communities First Foundation do not accept any liability for injury incurred by participating in the activity, either on or off the pitch, spectating or travelling to the venue. Communi
Yes
No
Any pre-existing medical condition
Yes
No
A oes gan unrhyw un o'ch plant anabledd? Ticiwch bopeth sy'n berthnasol i unrhyw un o'ch plant neu'r plant rydych chi'n gofalu amdanynt (Dim ond un y gallwch chi ei ddewis)
Anabledd Iechyd Meddwl
Anabledd Iechyd Corfforo
Anabledd dysgu
Dim anabledd
Mae'n well gen i beidio â dweud
A oes gennych unrhyw broblemau symudedd? (Dim ond un y gallwch ei ddewis)
Empty Answer Choice
Empty Answer Choice
Oes
Nad Oes
A oes gennych unrhyw brryderon ynghylch camdriniaeth domestig?
Oes
Nad oes
Dim eisiau dweud
Empty Answer Choice
A oes gennych unrhyw bryderon cyfredol ynghylch camddefnyddio alcohol neu gyffuriau? (Dim ond un y gallwch ei ddewis)
Empty Answer Choice
Oes
Nad Oes
dim eisiau dweud
Applications from ex-offenders are welcomed and will be considered on their merit. Convictions that are irrelevant to this job will not be taken into account. You are required to disclose any convictions, which are not 'spent' by virtue of the Rehabilitation of Offenders Act 1974. Have you been convicted of a criminal offence, which is not spent, as defined in the above Act in the UK?
Yes
No
Apprenticeship
Yes
No
Apprenticeship levels
L1- Traineeship
L2 -Intermediate Apprenticeship
L3 -Advanced Apprenticeship
L4- Higher Apprenticeship
L5 - Higher Apprenticeship
L6 - Degree
L7 - Masters Degree
L8 - Doctorate
Approximately, how much monthly disposable income AFTER housing costs, bills, loans?
Less than £250
£250 - £500
£500 - £750
£750 - £1000
£1000 - £1250
£1250 - £1500
£1500 - £1750
£1750 - £2000
+ £2000
Approximately how much monthly income BEFORE housing costs, bills, loans
Less than £250
£250 - £500
£500 - £750
£750 - £1000
£1000 - £1250
£1250 - £1500
£1500 - £1750
£1750 - £2000
+ £2000
Aptitude/ability for volunteering with over 60s
1
2
3
4
5
Area (Location)
Taunton
West Somerset
Taunton and West Somerset
National
Online
Area of expertise
Decoration
Cakes
Area of Expertise:
Art
Wedding Gowns
Drama coach
Play creator
Beutician
Foot care specialist
Bridal rental
Business coach
Clinical Hypnotherapist
Party Planner
Business owner
Catering Manager
Charity support worker
Children's clothing
Children's play scheme
Clothing store owner
Copy writer
Grant writer
Fundraiser
Counsellor
Therapist
Culinary Skills
Food Presentation
Dance Teacher
Digital Illustrator
Emotional support worker
Coordinator
Finance Officer
Fitness Instructor
Food Production
Form Teacher
Gift Store Owner
Grant writer
Teacher
Graphic Designer
Gardening
Headmistress
Head Teacher
Mechanechos
Home Beauty Business
Home Scents Shop
Initiator of New Organisations
Senior admin role
Interior Designer
Jewellery Seller
Ladies Clothing
Makeup Artist
Manager of Ofsted Playgroup
Office Administrator
Organisation Head
Organises tasks in office
Has spoken to Government
Biscuit decorating
Party Planner
Patisserie
Photo and video design
Photographer
Piano teacher
Programmer
Savoury platters
Seminary
SENCO management
Sewing
Gives Hilchos Shabbos Shiurim
Sheitel colouring and repairs
Sheitel Macher
Social issues at work
Student therapist
Studio and singing
Teacher
Medical dispatcher
Hatzola
Training program leader
Therapist
Training teacher
Language therapist
Voluntary sector leader
Writer in Jewish Tribune
Area of work
Children & Young People
Families
Adults
Drugs and alcohol
Sexual Health
Health
LGBT
BME
Other
Areas interested in
Accounting & Finance
Anthropology
Archaeology
Architecture
Art & Design
Biological Sciences
Business & Management Studies
Chemistry
Communication & Media Studies
Computer Science
Counselling
Criminology
Dentistry
Drama, Dance & Cinematics
Economics
Education
Engineering
English
Fashion
Film
Food Science
Geography & Environmental Sciences
Geology
History
History of Art, Architecture & Design
Hospitality, Leisure, Recreation & Tourism
Land & Property Management
Languages
Law
Librarianship & Information Management
Linguistics
Marketing
Mathematics
Medicine
Middle Eastern & African Studies
Music
Nursing
Occupational Therapy
Other
Pharmacology & Pharmacy
Philosophy
Physics
Physiotherapy
Politics
Psychology
Social Policy
Social Work
Sociology
Sports Science
Theology & Religious Studies
Veterinary Medicine
Youth Work
Are parent(s)/carer(s) aware of this referral?
Yes
No
Are Social Services involved with your children?
Yes
No
Are there any concerns in the following areas? Suicidal thoughts, Suicide attempts / self-harming behaviours / self - neglect / aggression/violence
Current concerns
History of Concerns
No Concerns
Are there any concerns regarding aggression/violence?
Current concerns
History of
No concerns
Are there any concerns regarding self-harming behaviours?
Current concerns
History of
No concerns
Are there any concerns regarding self-neglect?
Current concerns
History of
No concerns
Are there any concerns regarding suicidal thoughts?
Current concerns
History of
No concerns
Are there any concerns regarding suicide attempts?
Current concerns
History of
No concerns
Are there any health concerns we should be aware of?
Yes
No
Are there any known intergenerational risk factors around the child?
Parental substance misuse
Parent currently in custody
Parent with experience of custody
History of domestic abuse
Family known to YOS
Parental death
Are there any other health professionals involved in your treatment?
Yes
No
Are there any reasons you feel the above volunteer should not be involved in this type of volunteering
Yes
No
Are there any restrictions on you taking up employment in the UK?
Yes
No
Are there any safeguarding concerns that we as service providers need to be aware of?
Yes
No
Are there current mental health concerns?
Yes
No
Are there specific criminal or sexual exploitation concerns from within the professional network?
Yes
No
Are they Free School Meal eligible?
Yes
No
Are they in receipt of universal credit?
Yes
No
Are you a carer, or do you have Caring responsibilities?
Yes
No
Prefer not to say
Are you a Flintshire resident?
Yes
No
Are you a Housing Association Resident? We are asking for this information because sometimes we receive funding for those that are renting from certain housing associations i.e. Clarion.
Yes
No
Are you a lone parent (single adult household with department children)?
Yes
No
Prefer not to say
Are you a member of SBC
Yes
No
Are you an offender or ex-offender?
Yes
No
Prefer not to say
Are you a parent?
Yes
No
Prefer not to say
Are you a resident of Flintshire or Wrexham?
Flintshire
Wrexham
Neither
Are you completing this form for yourself or on the behalf of someone else?
For myself
For someone else
Are you currently a student?
Yes
No
Are you currently employed?
Yes
No
I'm a student
Are you currently expecting a baby?
Yes
No
Are you currently in education or training?
Yes
No
Are you currently pregnant?
Yes
No
Are you currently receiving or waiting to receive support from the Community Mental Health Team?
No
Yes
Are you currently receiving or waiting to receive support from the Community Mental Health Team or other Primary Care services?
Yes
No
Are you currently under investigation by the police?
Yes
No
Are you employed?
Yes
No
Empty Answer Choice
Empty Answer Choice
Are you engaged with the National Careers Service?
Yes
No
Unsure
Empty Answer Choice
Are you happy for film footage being used in publicity events arranged by Spadework? This might be in the newspaper, on our Website or Social Media.
Yes
No
Are you happy for us to use your photograph? In any information leaflet that we produce – such as the newsletters, and to tell people about Spadework.
Yes
No
Are you happy for your photograph to be used on our Website and Social Media?
Yes
No
Are you happy for your voice to be recorded and used in our Podcast and shared on Social Media to tell people about Spadework?
Yes
No
Are you happy to participate in this survey?
Yes
Are you happy to work in groups?
Yes
No
Are you homeless (broad definition)?
Yes
No
Prefer not to say
Are you in employment or education?
Employment
Education
Neither
Both
Are you in receipt of any benefits?
Job Seekers Allowance
Employment Support Allowance
Universal Credit
PIP/ADP
Family Tax Credit
Carer's Allowance
Government Payment
Other
None
Are you in receipt of benefits?
Yes
No
Are you in receipt of universal credit?
Yes
No
Are you on any medication (E.g. ant psychotics, antidepressents etc) or any medication that could cause drowsiness or where you should not operate machinery?
Yes
No
Are you or any of your family a refugee or asylum seeker?
Yes
No
Prefer not to say
Are you or your dependents subject to a legal care order?
Yes
No
Are you receiving support from any community/voluntary organisations? E.g. Citizens Advice, Womens Aid, Sure Start.
Yes
No
Are you recovering from drug and/or alcohol addiction or misuse?
Yes
No
Prefer not to say
Are you registered with a GP?
Yes
No
Are you taking the medication as prescribed?
Yes
No
Asian/Asian British
Indian
Pakistani
Bangladeshi
Chinese
Other
ASN
Yes
No
Aspiration required
Yes
No
Asset category
Church
Green space
Asthma
Yes
No
A) The social supermarket provides a form of food assistance that is respectful of people's dignity
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Attach their signed consent
English
French
German
Indian
Attendant
Staff
Volunteer
Attendee Type
Young people
Adult volunteers
Community members
Attends Meetings (ClickUp dropdown)
Yes
No
Availability
Monday- Sherborne
Tuesday- Yeovil
Thursday- Gillingham
Friday- Sherborne
All day , Everyday
A ydych chi a / neu'ch partner erioed wedi cael eich carcharu? (Dim ond un y gallwch ei ddewis)
Empty Answer Choice
Do
naddo
dim eisiau dweud
A yw'r Gwasanaethau Cymdeithasol yn ymwneud â'ch plant? (Dim ond un y gallwch ei ddewis)
Empty Answer Choice
Empty Answer Choice
Ydw
Nac Ydw
Bank Account
Yes
No
Barriers Identified
Housing: insecure housing
Digitally Excluded: Affordability: No equipment
Digitally Excluded: Affordability No service provision
Digitally Excluded: Poor network coverage
Financial: travel costs to training/interviews/education/voluntary work/upskilling
Financial: Child care costs
Financial: clothing
Digitally Excluded: Few skills
Financial: food charity
Housing: homelessness
Financial: fuel poverty
Housing: unaffordable housing
Vulnerable Adult - Mental Ill Health
Vulnerable Adult - Anxiety and Depression
Vulnerable Adult Other Long Term Illness
Learning Disability - Cognitive Impairment
Learning Disability - Non Neurotypical
Literacy and Numeracy Needs
English non first language
Sensory Impairment
Substance Misuse
Ex-offender
Care Leaver
Ex Military
Before completing this form, please indicate here if you are a professional who has consent to refer a parent, or if you are a parent registering with the Reach Children's Hub.
I am a parent registering with Reach Children's Hub
I am a professional referring a parent to Reach Children's Hub
Behaviour types
Disruptive in lessons
Physical violence towards adults
Physical violence towards other students
Verbally aggressive towards adults
Verbally aggressive towards other students
Displays signs of racial hatred
Self-harm
Dangerous use of property, equipment or other objects
Damage to property, equipment or other objects
Withdrawal (inwardly, e.g. sulking)
Withdrawal (avoidance e.g. walking off)
Attention seeking behaviours
Eating disorders
Substance abuse - please specify
Truanting lessons
Schools absence
Other - please specify
Being unfairly spoken over or not listened to in meetings.
Yes
No
Beth hoffech chi gofrestru ar ei gyfer?
Bwmp
Baban
Phlentyn
Therapi siarad
B) If I take the right steps, I can avoid problems.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
B) If someone opposes me, I can find means and ways to get what I want.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Bike Project
Project planing meeting
Community Event
Volunteering
Training
B) I/we could often skip a meal/go without food
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
B) I/we participate in a range of activities and interests in our local community
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
B) I/we regularly* eat processed meat, biscuits, sweets and chocolate
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Black/ African/Caribbean/Black British
African
Caribbean
Other
Borough
Lambeth
Lewisham
Southwark
Across boroughs
Boroughs
Camden
Kensington & Chelsea
Islington
Westminster
broad area of work
Employability
Learning
Mental Health & Wellbeing
Young Parents
Other
B) The social supermarket has helped me/ my family feel a part of our local community
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Business
Ades
AWIB
CAPWORTH
Copdat
Friends for All Project
Future Africa
Passionate
Review Energy
Church Pharmacy
IDASH
PADEAP
West Africa Tourism
Ajala Studios
ECIM
Global Native
ZIDIG
Commodity & General
Businesses
Ades
AWIB
Capworth
Friends for All Project
Future Africa
Passionate
Review Energy
Copdat
Church Pharmacy
IDASH
PADEAP
West Africa Tourism
Ajala Studios
ECIM
Global Native
ZIDIG
Commodity & General
Business Impact
SDG1
SDG2
SDG3
SDG4
Business they work for
Business 1
Business 2
Business 3
Buttle UK will use the information in this form to arrange your travel and accommodation for the Investing for the Future meeting and to contact you about this project. You can read more about how we use your information in our privacy policies: https://buttleuk.org/privacy-policies/
I agree for my data to be used in this way
Buttle UK will use the information in this form to decide who is invited to join Investing in the Future and to contact you about this project. You can read more about how we use your information in our privacy policies: https://buttleuk.org/privacy-policies/
I agree for my data to be used in this way
By submitting this form you are confirming that the following Privacy Notices have been made available to you and they explain how your data will be processed: (Please select all before submitting your form)
Wrexham County Council - https://www.wrexham.gov.uk/service/privacy-notice-prevention-and-support-service/privacy-notice-adult-community-learning-acl
CAHMS involvement
None
Historic
Current
Call Type
General Advice
Rehoming
Adoptions
Fundraising
Volunteering
Financial Assistance
Welfare Clinic
Abuse / Neglect
Wildlife
Food Bank
Other
Can the child/YP bear weight at all
Yes
No
Can the child/YP self propel the chair
Yes
No
Can they be orally fed
Yes
No
Can they self administer medication?
Yes
No
Empty Answer Choice
Empty Answer Choice
Can they self-transfer from their wheelchair without being hoisted
Yes
No
Can you commit to all sessions?
Yes
No
Can you commit to being on the panel for at least the next year?
Yes
No
Can you speak Welsh?
Yes fluently
Yes, but not fluently
No
Can you tell us how you heard about the Reach Children's Hub?
The Feltham Community Midwives
Feltham health visiting team
Reach Academy
Another Feltham school
Word of mouth
Other
Clinic app midwife gave leaflet
Friend
Midwife
Social Prescribing Service
Career change
Yes
No
Career Path / Desired Industries
Finance
HR
CSR
IT
Corporate
Administration
Customer Service
Banking
Front of House
Legal
Sports
Other
Career progression
Yes
No
Care-experienced
Yes
No
Previously
Don't Know
Care Leaver
No
Yes
Care Management Team
Adult Social Services in Medway Council
Autism & sensory team
Bexley Team
Dartford, Gravesend, S & S LD Team
Canterbury 26 plus
D G Swanley & Swade Y P team
DGSS 26 plus
Elly Church Kent Disability Team
Medway
Older Persons & Physical Disability Team
OPPD team
Southwark
West Kent YP Team
WK young persons
DGSS Young Persons
Canterbury Young Persons
WK 26 plus
Medway 25 Plus
Sensory and Autism Team
West Kent KCC
West Kent LD Team
Care status
CP
LAC
CIN
Assessment
Leaving care
None
Carries medication?
Yes
No
Unknown
Case Status
Open
Inactive
Closed
caseWorker.name
Beth McIvor
Bianca Neville
Ffion Haf
Gari Sparling
Janitah Salmon
Kate Zaczek
Katie Wood
Luke Mitchell
Pauliina Keinanen
Sharon Gough
Category
Council
Health
Education
Social Services
Justice system
Other
Category
NHS
Social Work
Police
Schools
Other Voluntary Organisation
Psychologist
Category field
1
2
3
Empty Answer Choice
Category field
why
how
whn
Empty Answer Choice
Category of referral partner
Addiction
Advocacy
Benefits & Finances
Bereavement
Carers Support
Abuse
Counselling
Courses
Disability
Eating Disorders
Children & Families
Education / Skills Development
Employment Support
Exercise & Leisure
GP Surgeries
Groups & Activities
Health & Wellbeing
Helplines
Homecare
Homelessness & Housing
Local Authorities / Health Board
Men's Mental Health
Mental Health
Older People
Social Services
Veterans
Volunteering
Young People
Category page
English
German
French
Hindi
cat field
1
2
3
Empty Answer Choice
cf
1
2
3
Empty Answer Choice
cf
1
2
3
Charge Rate
£40.91
£43.43
£45.88
£50.00
£55.00
£64.98
Charges (Training)
Breaking & Entering
Grievous Harm
Posession of drugs
Stealing
Check column
1
Child In Need?
Y
N
Child looked after?
Y
N
Child potentially/is at risk of harm?
Yes
No
Child protection
Yes
No
Child Protection Order
None
Historic
Current
Children or Adults
Children
Adults
Choose a gender
Male
Female
Other
Choose two things from the following list that are currently sources of motivation for you in your work at EasyMile:
Feeling like you are contributing to a higher goal and that the contributions you make are recognized
A steady income to support yourself and pay for somewhere to live, food, utilities and other essential needs
Feeling emotionally safe and supported
Feeling secure in your employment and not having to worry about losing your job due to layoffs
Feeling like you belong and fit in within your workplace and your team
Having access to social activities and opportunities for relationship-building with people from work
A comfortable working environment
Feeling that you’re growing, advancing and achieving results, and that those around you recognize those results
Feeling empowered and trusted to do bring the best of yourself to your work
Feeling like your skills and abilities are recognized and encouraged to grow, making you feel challenged at work but not overwhelmed or overloaded
Choose your setting
Reach Nursery
South Bedfont Pre-School
Sparrow Farm Primary
Harvard Park Feltham
St Richards Preschool
Small Steps
Tiny Toez
Parkside Playgroup
Little George's
Cardinal Road Nursery and Infant
West London Zone
Wendell Park Primary (out o Feltham)
Fairholme Primary
Southville Primary School
Earlsfield Primary School (out o Feltham)
Roxbourne Primary School (out o Feltham)
Once Upon Time Day Nurseries
St George's Day Nursery
Sacred Heart Catholic Primary School
Edward Pauling Primary School
Pomfrett Cottage Nursery
Springrove Primary School
George's Preschool
Meadhurst Primary School
St Lawrences
Linden Bennett
Southbedfont Preschool
Rosepark Nursery
St Albans Nursery
Once upon a time
Crane Park nursery
Fledglings Play Centre
Child minder
Springwest
Rivers Academy
Reach Academy Primary
Reach Academy Secondary
Logic Studio School
Space Studio School
Church/Volunteering place
All Saints, Four Oaks
All Saints, Gravelly Hill
All Saints, Grendon
All Saints, Kings Heath
All Saints, Shard End
All Saints, Small Heath
All Saints, Stechford
All Souls, North Warwickshire
Aston & Nechells
Bishop Latimer & All Saints, Birmingham
Castle Vale w Minworth
Christ Church, Oldbury
Christ Church, Quinton
Christ Church, Selly Park
Christ Church, Sparkbrook
Christ Church, Summerfield
Christ Church, Ward End
Christ Church, Yardley Wood
Christ the King, Erdington
Cofton Hackett & Barnt Green
Curdworth, Middleton, Wishaw
Dorridge and Bentley Heath
Elmdon
Emmanuel, Wylde Green
Holy Cross, Billesley Common
Holy Trinity (Resurrection), Smethwick
Holy Trinity, Birchfield
Holy Trinity, Sutton Coldfield
Immanuel, Highters Heath
Kings Norton Team
Kingsbury, Baxterley w Hurley Wood, Merevale with Bentley
Knowle
Lickey
Nicholas, Baddesley, Ensor
Old Church, Smethwick
Polesworth
Salter Street
Saltley and Washwood Heath
Shirley
Solihull Team
Sparkbrook and Balsall Heath
Sparkhill
SS Faith & Laurence, Harborne
SS Mary & Ambrose, Edgbaston
SS Mary & Bartholomew, Hampton- in Arden
SS Mary & Margaret, Castle Bromwich
SS Paul & Silas, Lozells
SS Peter & Paul, Coleshill
SS Peter & Paul, Water Orton
SS Philip & James, Hodge Hill
St Agnes, Moseley
St Alban the Martyr, Highgate
St Andrew, Chelmsley Wood
St Andrew, Handsworth
St Anne, Moseley
St Anne, West Heath
St Augustine of Hippo, Edgbaston
St Barnabas, Erdington
St Barnabas, Kingshurst
St Bartholomew (Old Church), Edgbaston
St Bartholomew, Allens Cross
St Bede, Brandwood
St Benedict, Bordesley
St Bernard, Hamstead
St Boniface, Quinton Road West
St Chad, Erdington
St Chad, Rubery
St Chad, Sutton Coldfield
St Christopher, Springfield
St Clement, Castle Bromwich
St Columba, Banners Gate, Sutton Coldfield
St Cyprian, Hay Mill, Yardley
St Edburgha, Yardley
St Editha, Amington
St Edmund, Tyseley
St Francis of Assisi, Bournville
St Gabriel, Weoley Castle
St George w. St Michael, Edgbaston
St George, Birmingham
St Germain, Edgbaston
St Giles, Packwood
St Giles, Rowley Regis
St Giles, Sheldon
St Hilda, Warley Woods
St James, Handsworth
St James, Hill
St James, Rounds Green
St John and St Michael, Langley
St John the Baptist, Harborne
St John the Baptist, Longbridge
St John the Ev & St Peter, Ladywood
St John the Evangelist
St John the Evangelist, Perry Barr
St John the Evangelist, Walmley
St Laurence, Northfield
St Leonard, Dordon
St Leonard, Frankley
St Leonard, Marston Green (Moved from Coleshill and Polesworth Deanery 2nd May 2024)
St Luke, Birmingham
St Luke, Kingstanding
St Margaret, Olton
St Mark, Kingstanding
St Mark, Londonderry
St Mark, Stockland Green
St Martin in-the-Bull-Ring, Birmingham
St Mary Magdalen, Hazelwell
St Mary Magdalene, Tanworth- in-Arden
St Mary the Virgin, Bearwood
St Mary the Virgin, Lapworth
St Mary the Virgin, Pype Hayes
St Mary the Virgin, Temple Balsall
St Mary, Acocks Green
St Mary, Handsworth
St Mary, Hobs Moat
St Mary, Moseley
St Mary, Selly Oak
St Mary, Wythall
St Matthew w. St Chad, Smethwick
St Matthew, Perry Beeches
St Michael & All Angels, Bartley Green
St Michael & All Angels, Maxstoke
St Michael & All Angels, South Yardley
St Michael, Baddesley Clinton
St Michael, Boldmere
St Michael, Hall Green
St Michael, Handsworth
St Paul, Balsall Heath
St Paul, Birmingham
St Paul, Blackheath
St Paul, Bordesley Green
St Paul, Dosthill
St Paul, Hamstead
St Swithin, Barston
St Peter, Balsall Common
St Peter, Bickenhill
St Peter, Hall Green
St Peter, Harborne
St Peter, Maney
St Peter, Tile Cross
St Philip's Cathedral, Birmingham
St Richard, Lea Hall
St Stephen & St Wulstan, Selly Park
St Stephen the Martyr, Rednal
St Thomas, Garretts Green
St Thomas, Nuthurst-cum-Hockley Heath
The Ascension, Hall Green
The Ascension, Stirchley
The Cotteridge Church
Whitacres, Lea Marston and Shustoke
Any deanery parish
Whole Deanery
C) It is easy for me to stick to my aims and accomplish my goals.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Citizen Status: Additional Information
Indefinite leave to remain/settled status
Limited leave to remain/pre settled status
Refugee
Asylum Seeker
Citizen Status: UK/ROI Citizen
Yes
No
City
Delhi
Faridabad
Haridwar
Imphal
C) I/we feel that I/we belong/ are part of our local community
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
C) I/we purchase foods that will not go to waste and that are most filling
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
C) I/we would regularly* eat a takeaway meal
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Class Type
Open
Team
Client is adult or child?
Adult
Child
Client's Age
16-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Prefer not to say
Client's Disability
Yes
No
Prefer not to say
Client's Ethnicity
White
Mixed
Multiple ethnic groups
Asian
Asian British
Black British
African
Caribbean
Other ethnic group
Prefer not to say
Client's Sex
Male
Female
Prefer not to say
Close family members involved in the criminal justice system?
Yes
No
C) Most things that affect my life happen by accident.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Colors
Blue
Green
Yellow
Red
Colours
Yellow
Pink
Blue
Purple
colours_abc
reed_
yellowww
piiink
Commercial job type - please specify
Broker
Business Advisory
Charterer
Commercial Analyst
Hedging Desk
Performance Analyst
Pool Manager
Project Manager
Risk Analyst
Sales / marketing / business development
Voyage Analyst
Commitment and Reliability
1
2
3
4
5
Commitment level
Full Time
Part Time
UoL Student
Communication
1
2
3
4
5
6
7
8
9
10
Communication
1
2
3
4
5
6
7
8
9
10
Communication Consent:: I consent to receiving updates about Sport 4 Life programs, events, and opportunities via [email, SMS, etc.]. View our policy here - https://sport4life.org.uk/privacy-policy/
Yes
No
Communication Methods
Phone
Letter
Email
Text
Voicemail
Communication Skills
1
2
3
4
5
Communications Preference
Email
SMS
Phone Calls
Empty Answer Choice
Community
Lodmoor
Westham
Melcombe Regis
Peak District
Dorchester
Portland
Community Event
Planning Meeting
Representing ESTEEM
Fundraising
Volunteering
Publicising
Public Speaking
Research
Networking
Confidence
1
2
3
4
5
6
7
8
9
10
Confidentiality: All the information you give is confidential unless you tell us something which means that there could be harm to you or another person, then we would need to share that information. Need to tick this to proceed.
Yes, understood and agreed
No (If selected, we cannot accept onto our project/s)
Confirmation aged over 16
No - I am under 16
Yes I am 16 or over
Confirming wanting service
Yes
No
Connect or PLUS
Cinnamon Connect
Connect PLUS
Cinnamon Advisor
Team
Consent
Yes
No
Consent for usage for promotional purposes (including social media):
Yes
No
Consent for usage in funding applications to funders:
Yes
No
Consent for usage reporting to funders:
Yes
No
Consent: Given
Yes
No
Contact Permissions - I would like you to contact me about:
General Vintage Vibes news & events
Vintage Vibes fundraising news
Contact Permissions - I would like you to contact me via:
Telephone
Email
Post
Contact regards
MHWB
Learning
TFIY
Young parents
Other
Conversations had to date
Potential Venue
Referral Agency
Community Speaker
Distribute Publicity
Other
Convict/Remand
Convict
Remand
Co-Trainer
Caroline Kerr
Cathy Murphy
Christine Chapman
Claire Giles
Deb Birch
Diane Laird
Gail Allan
Helen Gamble
Jean Deacon
Jen Rivett
Jo Anderson
Jo Tickle
Kathy Peto
Lisa Phillips
Liz Davies
Luce Carter
Lyndsay Harrison
Maggie Fisher
Mandy Habgood
Mary Duggan
Mary Taylor
Michelle Tucker
Moyra Adams
Peter Leonard
Rachel Walding
Rosie Hatton
Rowen Smith
Sara Bright
Sara Wiggins
Sarah Bojakowski
Sarah Darton
Sharon Lawton
Verity Lowe
Vicky Knight
Yvonne Hayes
country
English
French
German
Empty Answer Choice
Country
Kenya
Tanzania
Country
England
France
Germany
India
Country
Delhi
Faridabad
Haridwar
Imphal
Country
India
USA
UK
Canada
France
Africa
China
Russia
Australia
Hong Kong
Country
India
England
Germany
America
Empty Answer Choice
Country
England
Northern Ireland
Scotland
Wales
Country
Kenya
Uganda
Country live in
German
England
Denmark
China
India
Country of Birth
India
Australia
Sri Lanka
Spain
Italy
England
USA
Canada
Bhutan
Qatar
Bahrain
UAE
Nepal
China
Japan
Burma
Country of Birth
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
South Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Other
Country of Engagement
England
France
Country of Origin
Afghanistan
Albania
Algeria
Algeria
Antigua and Barbuda
Argentina
Armenia
Azerbaijan
Bahrain
Bangladesh
Barbados
Belarus
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
Chechnya (Russ. Fed.)
Chile
China
Colombia
Congo Brazzaville
Congo DRC
Costa Rica
Cuba
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Georgia
Ghana
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hongkong (China)
India
Indonesia
Iran
Iraq
Ivory Coast
Jamaica
Jordan
Kazakhstan
Kenya
Kosovo
Kurdistan Region Iraq
Kuwait
Kyrgyzstan
Laos
Lebanon
Lesotho
Liberia
Libya
Macedonia
Madagascar
Malawi
Malaysia
Mali
Mauritania
Mauritius
Mexico
Moldova
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nepal
Nicaragua
Niger
Nigeria
North Korea
Oman
Pakistan
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Puerto Rico
Qatar
Russia
Rwanda
Saudi Arabia
Senegal
Serbia
Sierra Leone
Singapore
Somalia
South Africa
South Korea
South Sudan
Sri Lanka
Sudan
Suriname
Swaziland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togolese Republic
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Uganda
Ukraine
United Arab Emirates
United States of America
Uruguay
Uzbekistan
Venezuela
Vietnam
Western Sahara (Morocco)
Yemen
Zambia
Zimbabwe
Country of Origin
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunel
Bulgaria
Burkina Faso
Belarus
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Burundi
East Timor
El Salvador
Equatorial Guinea
Ethiopia
Fiji
Finland
France
Germany
Ghana
Greece
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Hungary
Iceland
India
Israel
Italy
Ivory Coast
Jamaica
Japan
Kenya
Kiribati
Kyrgyzstan
Kuwait
Laos
Latvia
Lebanon
Marshall Islands
Mauritania
Mexico
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Niger
Nigeria
Norway
Oman
Pakistan
Panama
Paraguay
Peru
Philippines
Slovakia
Somalia
South Sudan
Syria
Togo
Tonga
Trinidad and Tobago
Tuvalu
United Arab Emirates
United States
Uruguay
Uzbekistan
Vatican City
Venezuela
Vietnam
Turkmenistan
Ecuador
Egypt
Eritrea
Estonia
Gabon
Gambia, The
Georgia
Grenada
Honduras
Indonesia
Iran
Iraq
Ireland
Jordan
Kazakhstan
Korea, North
Korea, South
Kosovo
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Mauritius
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Nicaragua
Palau
Palestein
Papua New Guinea
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierr Leone
Singapore
Slovenia
Soloman Islands
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Taiwan
Tajikistan
Tanzania
Thailand
Tunisia
Turkey
Uganda
Ukraine
United Kingdom
Vanuatu
Yemen
Zambia
Zimbabwe
Country they're based in
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Congo-Brazzaville)
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea=Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiriibati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine State
Panama
Papau New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Soloman Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuata
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country you live in
England
France
Germany
Denmark
Country you live in
England
France
Germany
Denmark
County
Oxfordshire
Surrey
Worcestershire
County
Baringo
Bomet
Bungoma
Busia
Elgeyo Marakwet
Embu
Garissa
Homa Bay
Isiolo
Kajiado
Kakamega
Kericho
Kiambu
Kilifi
Kirinyaga
Kisii
Kisumu
Kitui
Kwale
Laikipia
Machakos
Marsabit
Migori
Mombasa
Murang'a
Nairobi
Nakuru
Nandi
Narok
Nyamira
Nyeri
Samburu
Siaya
Taita Taveta
Tana River
Turkana
Uasin Gishu
Vihiga
Wajir
Lamu
Mandera
Meru
Tharaka Nithi
Makueni
Nyandarua
West Pokot
Trans Nzoia
Course Delivery Type
In Person
Online
Co-working space
Yes
No
CP-6302 Test
1
2
3
CP Register
Yes
No
Created By
Eimear North
Empty Answer Choice
Empty Answer Choice
Empty Answer Choice
Criminal exploitation concerns
No
Yes
Crop variety
Beans
Corn
Radishes
CRP Category
Poverty
Families, Children and Young People
Elderly
Health
Safer communities
C) The facilities in terms of the community space at the social supermarket are of a high quality.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Current behaviour
Occasional behaviour issues (in/out of class)
Frequent behaviour issues outside of class
Frequent behaviour issues in class (with/without issues at break times)
Frequent or recent fixed-term exclusions
Close to permanent exclusion
Current concerns around domestic violence?
No
Yes
Current level of education?
ISCED 0 - Lacking foundational skills
ISCED 1 - Entry level functional skills/Entry level foundation learning
Currently Involved in early help or family support services?
No
Yes
Currently on bail?
Yes, police bail
Yes, court bail
No
Currently on CP/CIN plan
Yes
No
Current parenting status
Two-parent family
Single parent
Step parent
Foster parent
Grandparent
Relative/Family friend
Non-resident parent
Educator/advocate
Other
Current political opinion: what is your current political opinion?
Nationalist
Unionist
Other
None
Prefer not to say
C/YP Plan
Yes
No
Data Collection and Usage Consent: I consent to the collection and use of my personal information for the following purposes: Facilitating my participation in Sport 4 Life programs and events. Communicating important updates and information. Assessing the impact of Sport 4 Life's activities. View our policy here - https://sport4life.org.uk/privacy-policy/
Yes
No
Data consent. Why do we need this information? Reach Children’s Hub needs to keep this information in order to contact you regarding updates, upcoming events or emergencies. Additionally, we are bound by our contracts to report some of this information (e.g. gender, age, ethnicity and post code) to our funders. Confidentiality Personal information you discuss with staff and provide here will be kept confidential. This information will be kept securely on password protected devices, networks and software to which only authorized members of Reach Children’s Hub will have access to. In the rare case when you disclose information to us that suggests you or someone else is likely to suffer harm or that a crime is going to be committed, we have a duty of care to report this to the relevant agency. In this situation, we do not need your permission but will inform you of our concerns and let you know who we will be passing the information on to. From time to time we may need to share information with local services. Wherever possible, we will seek consent and be open and honest as to why, what, how and with whom, your information has been shared.
Yes
Data Policy info - tick if read
Yes
No
Data Protection
Consent Notification Provided
Text Message sent to Emergency contact (if under 18)
Explained How data will be stored
Explained how data will be processed and protected
Data protection: I confirm that the above information is complete and correct. I consent to the processing of this data in the consideration of my application and during the course of my volunteering, where applicable.
Yes
Data Protection opt-in
Yes
No
Date of birth
English
French
German
Indian
Dates
Date 1
Date 2
Date 3
Date 4
Date 5
Date 6
Date 7
Date 8
Date 9
Date 10
Day Hired
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
None
Day of the week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Deal Source type
Partner
Ads
Cold Sales
Warm Sales
Upsell
Customer Referral
Deanery
Aston & Sutton Coldfield
Coleshill & Polesworth
Yardley & Solihull
Kings Norton, Moseley & Shirley
Warley & Edgbaston
Handsworth & Central
Deceased?
Yes
No
Decision
Short-listed
Reserve list
Not short-listed
Delivery Mode
Online
Face to Face
Delivery organisation
Abri (Taunton)
Access to Learning and Employment Grant (Somerset West and Taunton)
CPAG - Your Work Your Way Project (Taunton)
Discovery (Bridgwater)
Food cupboard (Minehead)
Food cupboard (Watchet)
Food Cupboard (Williton)
Homestart (Minehead)
Job Centre Plus (Minehead)
Job Centre Plus (Taunton)
MIND Somerset (Somerset West and Taunton)
National Career Service (Taunton)
National Career Service (West Somerset)
Navigate (Taunton)
Positive People (Taunton)
Positive People (West Somerset)
Restart programme (Taunton CMT services)
Restart programme (West somerset CMT services)
Serco (National)
Skill UP (Taunton)
Skill UP (West Somerset)
Somerset West and Taunton
SomersetWorks (Somerset West and Taunton)
Taunton Citizens Advice (Taunton)
Taunton Workwise (Taunton)
Young Somerset (Somerset)
Delivery Partner
Art Gene
CAfS
PACT
Shared Future
Simply Repair
Sustainable Carlisle
Vista Veg
Denomination
Christian
Islamic
Hinduist
Buddhist
Irreligious
Folk religious
Other religion
Prefer not to say
Department
Emotionally Healthy Living
Facilitation Training
Parent Groups
Department
Fundraising
Front-line support
Human Resources
Finance
Management
Marketing, Communications and Publications
Events
Programmes & Services
Campaigning & Lobbying
Research, Data and Insight
Operations & Strategy
Department:-
Customer Support
Engineering
Finance
HR
Operations
Marketing
Research
Sales
Strategy
Dependants: Do you have a personal responsibility for the care of any of the following?
A child (or children)
A person(s) with a disability
A dependant adult(s)
None
Description of Expenses on Dates
Date 1 Description
Date 2 Description
Date 3 Description
Date 4 Description
Date 5 Description
Date 6 Description
Date 7 Description
Date 8 Description
Date 9 Description
Date 10 Description
Details of Disability
Hearing Impairment
Learning Disability
Long standing illness or health condition
Mental Health Condition
Physical Impairment
Vision Impairment
D) I am confident that I could deal efficiently with unexpected events.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Did the church have an original mission statement or plan when formed?
Yes
No
Did these issues have an impact on education?
Yes
No
Did you get permission from the child's parents for the child's information to be inputted on Makerble?
Yes
Did you have a Reader / Writer / Extra time (for work or exams. You will need to show us paperwork so we can arrange extra time for RV exams
Disability: Do you have a disability as defined by the disability Discrimination Act 1995?
Yes
No
Prefer not to say
Discipleship connection type
Exploring faith
Initial connection
Nurturing faith
N/A
District.County
Embu
Kiambu
Krinyaga
Laikipia
Meru
Muranga
Mwanga
Nyeri
Rombo
Sihi
Tharaka Nthi
District List
Abim
Adjumani
Agago
Alebtong
Amolatar
Amudat
Amuria
Apac
Arua
Budaka
Bududa
Bugiri
Bugweri
Buhweju
Buikwe
Bukedea
Bundibugyo
Bunyangabu
Bushenyi
Busia
Butaleja
Butambala
Butebo
Buvuma
Buyende
Dokolo
Gomba
Gulu
Hoima
Ibanda
Iganga
Isingiro
Jinja
Kaabong
Kabale
Kabarole
Kaberamaido
Kagadi
Kakumiro
Kalangala
Kaliro
Kalungu
Kampala
Kamuli
Kamwenge
Kanungu
Kapchorwa
Kapelebyong
Karenga
Kasanda
Kasese
Katakwi
Kayunga
Kazo
Kibaale
Kiboga
Kibuku
Kibuube
Kiruhura
Kiryandongo
Kisoro
Kitagwenda
Kitgum
Koboko
Kole
Kotido
Kumi
Kwania
Kween
Kyankwanzi
Kyegegwa
Kyenjojo
Kyotera
Lamwo
Lira
Lusot
Luuka
Luweero
Lwengo
Lyantonde
Madi-Okollo
Manafwa
Maracha
Masaka
Masindi
Mayuge
Mbale
Mbarara
Mitooma
Mityana
Moroto
Moyo
Mpigi
Mubende
Mukono
Nabilatuk
Nakapiripirit
Nakaseke
Nakasongola
Namayingo
Namisindwa
Namutumba
Napak
Nebbi
Ngora
Ntoroko
Ntungamo
Nwoya
Obongi
Omoro
Otuke
Oyam
Pader
Pakwach
Pallisa
Rakai
Rubanda
Rubirizi
Rukiga
Rukungiri
Rwampara
Sembabule
Serere
Sheema
Sironko
Soroti
Tororo
Wakiso
Yumbe
Zombo
Districts of the Gambia
Central Baddibu
Foni Bintang-Karenai
Foni Bondali
Foni Brefet
Foni Jarrol
Foni Kansala
Fulladu East
Fulladu West
Jarra Central
Jarra East
Jarra West
Jokadu
Kantora District
Kiang Central
Kiang East
Kiang West
Kombo Central
Kombo East
Kombo North/Saint Mary
Kombo South
Lower Baddibu
Lower Niumi
Lower Saloum
Niamina Dankunku
Niamina East
Niamina West
Niani District
Nianija
Sami District
Sandu District
Upper Baddibu
Upper Niumi
Upper Saloum
Wuli District
D) I/we generally consume cheaper foods, than can be nutrient-poor but calorie-rich
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
D) I/we would have a good understanding of healthy eating practices (e.g. not skipping breakfast; 5-a-day guidelines, avoiding high fat and high sugar snacks and controlling salt intake)
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Do any of your children have a disability? Tick all that apply to any of your children or the children you care for
Mental Health disability
Physical Health disability
Learning disability
No disability
Prefer not to say
Does anyone in the household describe themselves as LGBTQ+
Yes
No
Prefer not to say
Does the child have any diagnosed disabilities?
Yes
No
Does the child have any disabilities or learning needs?
Yes
No
Unknown
Does the child have any offences of serious violence on their record and/or any outstanding court proceedings in relation to serious violence?
Yes
No
Unknown
Does the child have asylum or immigration status?
Yes
No
Does the child have refugee, asylum or immigration status?
Refugee (Legally recognised)
Asylum seeker (Hasn’t yet been legally recognised as a refugee and is waiting to receive a decision on their asylum claim)
Unaccompanied Asylum Seeking Child
Migrant/Immigrant (staying outside their country of origin, not an asylum seeker or refugee)
None
Unknown
Does the child need help with continence aids
Yes
No
Does the child speak English as an additional language?
Yes
No
Unknown
Does the child/YP recieve medicine through their tube
Yes
No
Does the Child/YP take daily epilepsy Medication
Yes
No
Does the Child/YP take emergency epilepsy medication
Yes
No
Does the child/YP use braces/second skin
Yes
No
Does the client consent to further measures of referral/plans/support?
Yes
No
Unable to establish
Does the client have a significant other?
Yes
No
Does the client have dependents? (Either children or adults)
Yes
No
Does the individual have any mobility issues?
Yes
No
Does the individual want to change any aspect(s) of their life?
Yes
No
Does their Monthly Fee affect future cashflow of next 12 months
Yes
No
Does their Monthly Fee affect future cashflow of next 13-36 months
Yes - if retained
Yes
No
Does the YP experience any other type of seizure that has not been mentioned above?
Yes
No
Does this person use a wheelchair?
No
Yes but can transfer
Yes but unable to transfer
Does your child ever have to be held to keep them from hurting themself or others?
Yes
No
Does your child ever need to be held to be kept safe?
Yes
No
Does your child ever need to be held to be kept safe? (If yes, safe holding information to be completed)
Yes
No
Does your child go to Reach Academy?
Yes
No
Does your child have allergies
Yes
No
Does your child have any additional needs that we should be aware of?
Yes
No
Does your child have any dietary requirements or allergies we should be aware of?
Yes
No
Does your child have any support requirements around feeding (routines, allergies, restrictions and preferences)
Yes
No
Does your child require suctioning?
Yes
No
Don't use- 6. What is your nationality?
Afghan
Albanian
American
Argentine
Australian
Austrian
Bangladeshi
Belgian
Brazilian
British
Bulgarian
Burmese
Canadian
Chiliean
Chinese
Colombian
Croatian
Cuban
Cypriot
Danish
Dutch
Egyptian
English
Estonian
Fijian
Filipino
Finnish
French
German
Ghanaian
Greek
Hong Konger
Hungarian
Indian
Indonesian
Irish
Italian
Japanese
Kenyan
Latvian
Lebanese
Lithuanian
Macedonian
Malaysian
Manx
Mexican
Moldovan
Montenegrin
Nigerian
Northern Irish
Norwegian
Other (Please specify)
Other (Please specify)- American
Other (Please specify)- I identify as a person from Mars and I find this question highly offensive
Other (Please specify)- Xxx
Pakistani
Palestinian
Panamanian
Peruvian
Polish
Portuguese
Romanian
Russian
Saudi
Scottish
Singaporean
Slovak
Slovenian
South African
South korean
Spanish
Sri Lankan
Swedish
Taiwanese
Turkish
Ukrainian
Venezuelan
Vietnamese
Welsh
Zimbabwean
DON'T USE-vHow long is your usual seafaring contract?
2-3 months months in duration
3-6 months in duration
6-9 months in duration
9-12 months in duration
Other
Do they have disabilities?
Yes
No
Do they have epilepsy? - if yes, please refer to NHS Epilepsy Plan
Yes
No
Empty Answer Choice
Empty Answer Choice
Do they pay for sessions
Yes
No
Do they require tube feeding
Yes - complete tube feeding form
No
Empty Answer Choice
Empty Answer Choice
Do they use incontinence aids?
No
Yes - just urine
Yes - just faeces
Yes - both
Do you believe more should be done to prevent animal abuse where you live?
Yes
No
Do you carry the medication with you?
Yes
No
Do you consent for us to carry out emergency First Aid on your child if necessary.
Yes
No
Do you consent for your child to be contacted directly via their school email address?
Yes
No
Do you consent to the above?
Yes
No
Do you consent to your child attending events, workshops & sessions as part of this programme?
Yes
No
Do you consent to your child's photo/video being taken?
Yes
No
Do you consent to your child traveling to and from events independently?
Yes
No
Do you consent to your personal data being shared with the partners, employers and support team on this programme?
Yes
No
Do you consider this to be an urgent referral (i.e., are you concerned about the safety of the young person)?
Yes
No
Do you consider yourself to be disabled?
Yes
No
Do you consider yourself to be disabled under EA10?
Yes
No
Prefer not to say
Do you consider yourself to have a disability?
Yes
No
Prefer not to say
Do you consider yourself to have a disability?
Mental Health disability
Physical Health disability
Learning disability
No disability
Prefer not to say
Do you consider yourself to have a disability or health condition?
Yes
No
Prefer not to say
Do you currently have a pension scheme and would like your contributions (post probationary period) to be added to this pension scheme
Yes
No
Do you currently receive support from any other organisations? E.g. Simon Community, Social Services, Extern, Day Opportunities, Community Mental Health Team etc
Yes
No
Do you currently work or volunteer in any other organisation?
Yes
No
Do you eat at least 5 fruits or vegetables daily?
I eat them once a week
I eat them twice a week
I eat them more than 3 days a week
I eat them very day
No, I don’t like fruits and vegetables
I eat them when I have to
Do you eat at least one hot meal cooked at home a day?
Yes
No
Do you feel that the wrap around support helped you to identify issues to improving current situation?
Yes
No
Do you feel that the wrap around support helped you/ your household to identify solutions to overcome these?
Yes
No
Do you find it hard to ignore distractions?
Yes
No
Sometimes
Do you give consent for us contacting the organisation(s), if required
Yes
No
Do you give consent to SLTH providing sun-cream if deemed necessary?
Yes
No
Do you give consent to your details to be stored....
Yes
No
Do you have a bank account?
Yes
No
Prefer not to say
Do you have a child under the age of 12 months?
Yes
No
Do you have a child under the age of 16 years?
Yes
No
Do you have a child under the age of 18?
Yes
No
Do you have a clean driving license? (not necessary for all roles)
Yes
No
Do you have a diagnosis of Autism
NHS Diagnosis
On the Waiting List for Diagnosis
Private Diagnosis
No Diagnosis - Identify as Autistic
No Diagnosis - Do not identify as Autistic
Do you have a driving licence?
Yes
No
Do you have a GP?
Yes
No
Prefer not to say
Do you have a hearing impairment?
Yes
No
Do you have a heart condition?
Yes
No
Do you have an asthma action plan?
Yes
No
Do you have any caring responsibilities?
None
Primary carer of a child
children (under 18)
Primary carer of a disabled child
Children (under 18)
Primary carer of a disabled adult (18 and over)
Primary carer of an older person
Secondary carer (another person carries out the main caring role
Do you have any communication needs?
Yes
No
Do you have any concerns about your life or safety?
Yes
No
Prefer not to say
Do you have any concerns regarding domestic abuse?
Yes - current
Yes - previous
No
Do you have any criminal unspent charges or convictions (under the Rehabilitation of Offenders Act 1974)? (NB: this does not necessarily prevent you from volunteering)
Yes
No
Do you have any current concerns around alcohol or drug misuse?
Yes alcohol
Yes drugs
Yes alcohol and drugs
No
Prefer not to say
Do you have any current convictions pending charge, ongoing legal issues or are you subject to a legal order(s)? E.g. Non-Molestation Order, Occupational Order, Contact Order etc.
Yes
No
Do you have any eating disorders?
Yes
No
Do you have any entry level, level 1, or level 2 qualification in English, maths or ESOL?
Yes
No
Do you have any health conditions?
Yes
No
Prefer not to say
Do you have any health issues, care or support needs or disabilities that we should be aware of?
Yes
No
Do you have any health / physical conditions that impact your day to day? (e.g. eyesight, mobility etc.)
Yes
No
Do you have any involvement with Social Services?
Yes
No
Do you have any medical conditions or food allergies/intolerances that we need to be aware of?
Yes
No
Do you have any mental health needs/ concerns?
Yes (often)
Yes (sometimes)
Not sure
No (rarely)
No (Never)
Do you have any mobility issues?
Yes
No
Do you have any mobility issues?
Yes
No
Do you have any of these health conditions?
Asthma
Diabetes Type 1
Diabetes Type 2
Epilepsy
Heart Condition
Low blood pressure
High blood pressure
ME/MS
Immune disorder
Allergy
Mental Health Illness
Other Condition
Do you have any other chest/breathing issues?
Yes
No
Do you have any past/present involvement with the criminal justice system?
Yes
No
Do you have any reading or writing difficulties?
Yes
No
Do you have a particular Religion or belief?
Yes
No
Prefer not to say
Do you have a valid enhanced DBS with children's barred list and currently registered with the update service?
Yes
No
Do you have a visual impairment?
Yes
No
Do you have children under the age of 12 months?
Yes
No
Do you have children under the age of 16?
Yes
No
Do you have children under the age of 5?
Yes
No
Do you have / have had any Mental Health issues that you would like to your tutor to be aware of?
Yes
No
Do you have the client's consent to refer to us?
Yes
No
Do you have to keep to any special diet?
Yes
No
Do you know when you are getting anxious?
Always
Sometimes
Never
Do you live in Housing Executive Accommodation?
Yes
No
Do you need any additional support to take you medication?
Yes
No
Do you, or have you worked with any outside support agencies eg CAMHS
Yes
No
Do you or your child (for under 18’s) have any access or communication needs?
Yes
No
Do you or your child (for under 18s) have any known health needs? E.g. Diabetes, asthma, epilepsy, allergies
Yes
No
Do you receive any benefits listed below? We are asking for this information because sometimes we receive funding for those that are in receipt of specific benefits.
Rather not say
Disability Living Allowance (DLA)
Personal Indepandence Payment (PIP)
Free School Meals / Pupil Premium
Carers Allowance
Child tax Credit
Employment and Support Allowance (ESA)
Housing Benefit
Income Support
Jobseekers Allowance (JSA)
Pension Credit
Universal Credit
Working Tax Credit
None of the Above
Other
Do you receive short breaks funding or direct payments? We are asking for this information because sometimes we receive funding for those that are in receipt of certain funding types.
Yes
No
Do you require a Personal Assistant to attend Spadework with you?
Yes
No
Do you require specific access to a building?
Yes
No
Do you suffer from any mobility difficulties?
Yes
No
Do you suffer from asthma or hay fever?
Yes
No
Do you suffer from diabetes?
Yes
No
Do you suffer from epilepsy or blackouts?
Yes
No
Do you suffer from high or low blood pressure?
High blood pressure
Low blood pressure
No
Do you suffer from high or low blood pressure?
Yes
No
Do you suffer from migraines or headaches?
Yes
No
Do you suffer with anxiety or stress?
Yes
No
Do you take medication for any of the conditions above?
Yes
No
Do you travel independently?
Yes
No
Do you understand English?
Yes
No
Do you wear glasses?
Yes
No
Do you wear hearing aids?
Yes
No
Do you work from home
Yes
No
Driving licence
Yes
No
Drop In
Planning Meeting
Drop In Session
Training
New Skill Learnt
Trip
Cooking
Additional Social Activity (new friend, party, comicon etc.)
DSO received verbal report prior to submission of ICD?
Yes
No
D) The development of the social supermarket has benefitted our local community.
Black/African/Caribbean/Black British: 16. Any other Black/African/Caribbean background/Caribbean background
Other ethnic group: 17. Arab
Other ethnic group: 18. Any other ethnic group
Ethnicity
White
Asian
Black
prefer not say
Ethnicity
White British
White Other
Black
Asian
Mixed Race
Other
Ethnicity
Indian
Spanish
French
british
Ethnicity
White
Black
Asian
Prefer not to say
Ethnicity
Asian
White British
Black British
Mixed
Ethnicity
White
Black
Ethnicity
Black
Chinese & other Asian
Indian, Pakistani & Bangladeshi
Mixed
White
Other
Prefer not to say
Hispanic, Latino, Spanish Origin
Hispanic, Latino & Spanish
Native Hawaiian & Other Pacific Islander
American Indian or Alaskan Native
Ethnicity
British
Irish
Gypsy or Irish Traveller
African
Caribbean
Indian
Pakistani
Bangladeshi
Chinese
Arab
Other White background
Other Black background
Other Asian background
Other
Ethnicity
White – English/Welsh/Scottish/Northern Irish/British
White – Irish
White – Gypsy or Irish Traveller
White – Other
Mixed – White and Black Caribbean
Mixed – White and Black African
Mixed – White and Asian
Mixed – Other
Asian – Indian / British Indian
Asian – Pakistani / British Pakistani
Asian – Bangladeshi / British Bangladeshi
Asian – Chinese
Asian – Other
Black – African / African British
Black – Caribbean / Caribbean British
Black – Other
Arab
Any other ethnic group, please specify
Prefer not to say
Ethnicity
White - English/Welsh/Scottish/Northern Irish/British
African
Asian
Ethnicity
Other
Black or Black British
European
Mixed - multiple ethnic background
White British
White Other
Asian or Asian British
Prefer not to say
Ethnicity
White
Black
Asian
Prefer not to say
Ethnicity
White
Black
Asian
Prefer not to say
Ethnicity
English
French
German
Italy
Ethnicity*
Asian/Asian British
Black, African, Caribbean or Black British
Mixed or Multiple ethnic groups
Other ethnic group
White
Ethnicity - for internal use only
Asian/Asian British: Bangladeshi
Asian/Asian British: Indian
Asian/Asian British: Other
Asian/Asian British: Pakistani
Black/Black British: African
Black/Black British: Caribbean
Black/Black British: Other
Chinese
Mixed: Other
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
White: British
White: Irish
White: Other
Ethnicity Group
Black British
Black Carribean
Black African
Ethnicity II
Black/Black British
Asian/Asian British
White British
Mixed
Other
Ethnicity (standard)
Asian: Chinese
Asian: Indian
Asian: Pakistani
Black: African
Black: African Caribbean
Latin American
Mixed: Indo-Caribbean
Mixed: Chinese
White: British
White: British/Swiss
White: South African
White: Canadian
Other ethnic group
Mixed/multiple ethnic groups
Asian/Asian British
Event attended
Event 1
Event 2
Event 3
Event 4
Existing Member?
Yes
No
Ex-Officio Membership Type
Local Business Partner
Policy Maker
Small Business Partner
Community Partner
User Group
Land Manager
DMO/Chamber
Expense Month
Jan
Feb
March
April
May
June
July
August
September
October
November
December
Experience
Teaching
Health
Business
Other
Eye Color
Brown
Green
Blue
Black
EYE COLOUR
Blue
Green
Brown
Facilitator 2 first time facilitator or not yet accredited? (List)
Yes
No
Faith
Christian
Muslim
Hindu
No Religion
Faith communities worked with
Buddhist
Christian
Hindu
Muslim
Sikh
Faith / Religion / Belief
No Religion
Christian
Buddhist
Hindu
Jewish
Sikh
Muslim
Other
Family/Home Based Experiences
Cramped or impermanent accommodation
Young carer
Siblings with special needs
Bereavement
Asylum seeking status
Refugee status
In foster care
Limited or lack of positive role models
familyStatus
SINGLE PARENT OVER 21 + CHILDREN
SINGLE PARENT UNDER 21 + CHILDREN
TWO PARENTS, OR PARENT LIVING WITH PARTNER + CHILDREN
YOUNG PERSON - ESTRANGED, UNDER 21
SINGLE GUARDIAN - RELATIVE OR FRIENDS + CHILDREN
TWO GUARDIANS - RELATIVE OR FRIENDS + CHILDREN
Family Unit
Couple
Single Mum
Living with parents
Single
Couple
fav language
English
Spanish
French
Hindi
Fav music
Pop
Rock
Raggae
Indie
Fav music
Hip hop
Pop
RnB
Alt
Favorite Food
Cheese
Bread
Rice
Fish
Favorite movies
Avengers
Transformers
Spiderman
Empty Answer Choice
Favorite sport?
Football
Basketball
Sport5-New
Sport6
Sport7
Sport7
Sport9
Sport10
Sport11
Sport12
Sport13
Sport14
Sport15
Sport16
Sport17
Sport18
Sport19
Sport20
Sport21
Sport22
Sport23
Sport24
Sport25
Sport26
Sport27
Sport28
Sport29
Sport30
Sport31
Sport32
Sport33
Sport34
Sport35
Sport36
Sport37
Sport38
Sport39
Sport40
Sport41
Sport42
Sport43
Sport44
Sport46
Sport47
Sport48
Sport49
Sport50
Sport51
Sport52
Sport53
Sport54
Sport55
Sport56
Sport57
Sport58
Sport59
Sport60
Sport61
Sport62
Sport63
Sport64
Sport65
Sport66
Sport67
Sport68
Sport69
Sport70
Sport71
Sport72
Sport73
Sport74
Sport75
Sport76
Sport77
Sport78
Sport79
Sport80
Sport81
Sport82
Sport83
Sport84
Sport85
Sport86
Sport87
Sport88
Sport89
Sport90
Sport91
Sport92
Sport93
Sport94
Sport95
Sport96
Sport97
Sport98
Sport99
Sport100
Sport101
Favourite Colour
Pink
Blue
Purple
Indigo
Violet
Orange
Favourite food
Cheese
Bread
Rice
Poha
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Food
Cheese
Bread
Rice
Fish
Favourite Place
Delhi
Bombay
Chennai
Mumbai
Favourite Snacks
Wafers
Doritos
Oreos
Cheetos
FC Policy Initiatives
Local Government
National Government
Local Businesses
VCSEs
FCP stakeholders are openly discussing the feasibility of projects and coming up with a working solution
Strongly Disagree
Moderately Disagree
Neither Agree/Disagree
Moderately Agree
Strongly Agree
Featured Event
Yes
No
F) I can solve most problems if I invest the necessary effort.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
File tracing process completed?
Yes
No
Empty Answer Choice
Empty Answer Choice
Film director
Woody allen
Steven Spielberg
Christopher Nolan
Greta gerwig
Quentin Tarantino
Films
Titanic
The little mermaid
Rush-hour
The Matrix
Pride and prejudice
Films
Titanic
Finance/HR/Admin/Support job type - please specify
Administration
Business support
Business Support Manager
Cash Flow
Company accounts / finance
Credit analyst
Crewing
Financial Analyst
HR
Invoicing
Other (Please specify
Other (Please specify) - ACCOUNTS
Other (Please specify) - Accounts Payable
Other (Please specify) - Accounts Reporting
Other (Please specify) - Admin, Company accounts / Financial Analyst, invoicing and much more
Other (Please specify) - AP
Other (Please specify) - AP/AR
Other (Please specify) - Assistant accounts officer
Other (Please specify) - CLIENT REPORTING
Other (Please specify) - Communications
Other (Please specify) - Compliance
Other (Please specify) - Controlling
Other (Please specify) - Corporate Accountant
Other (Please specify) - Crew Welfare
Other (Please specify) - DA
Other (Please specify) - Documentation Analyst/Custom
Other (Please specify) - end to end process and reports
Other (Please specify) - Equipment Coordinator
Other (Please specify) - ESG Lead
Other (Please specify) - Facility
Other (Please specify) - Final Wage Account
Other (Please specify) - Finance Officer
Other (Please specify) - Financial Reporting
Other (Please specify) - GL
Other (Please specify) - HOF
Other (Please specify) - HSEQ
Other (Please specify) - N/A
Other (Please specify) - Operations
Other (Please specify) - Resident Management
Other (Please specify) - SAFETY AND QUALITY
Other (Please specify) - Senior Accounts Officer
Other (Please specify) - Strategist
Other (Please specify) - Supply Chain Management
Other (Please specify) - Time Charter Accountant
Other (Please specify) - Vessel Accountant
Other (Please specify) - Vessel Accounting
Other (Please specify) - Vessel Accounts
Other (Please specify) - Visa Applications
Other: Dry Dock Superintendert
PA
Payroll
Procurement
Talent Acquisition
Trade accounts / finance
Training
Travel Coordinator
Treasury
First time facilitator (2) or not yet accredited?
Yes
No
First time facilitator or not yet accredited?
Yes
No
F) I/we have access to recipes and knowledge on health eating practices
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
F) I/we have inadequate intake of certain nutrients and fruits and vegetables
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Fluency in English
Fluent in English or English is first language
Limited English
No English at all
FME
Yes
No
Focus- event
Reducing isolation
Reducing anxiety
Building confidence
Building peer networks
Focus- Outreach sessions
Reducing isolation
Participation
Keeping safe
Food
Apple
Banana
Cookies
Cereal
Food bank user
Yes
No
Food bank worker's Role
Deputy Project Manager
Distribution Room Volunteer
Lead Volunteer Wellington Hub
Packing Volunteer
Project Manager
Trustee
Trustee & Volunteer
Trustee & Warehouse Volunteer
Volunteer
Volunteer Van Driver
Warehouse Volunteer
Wellington Volunteer
Wiveliscombe Volunteer
Food & Nutrition
1 Child is stable and not in need of support
2 Child is in need of food support
3 Child is acutely in need of food support
4 Child is at risk of starvation
Form
1Lemon
1Rowan
2Beech
2Birch
3Elder
3Maple
4Ash
4Elm
5Oak
5Sycamore
6Leam
6Thames
ROrchid
RPalm
7Derwent
7Liffey
8Avon
8Taff
9Clyde
9Eden
10Foyle
10Neath
11Mersey
11Wensum
Free school meals
Yes
No
Free School Meals?
Y
N
Free school meals (FSM)
Yes
No
From the list below, please click 3 areas that you think you would benefit from most whilst you are on the RESET programme
Money Management Course (Explains basic money skills & how to take control of personal finances)
Job Club (Personal skill, training & employability development)
Eat Well Spend Less (Cooking & budgeting course equipping people to cook from scratch)
Debt Counselling/Support (Advice & practical assistance to empower people to help themselves out of debt, whilst teaching essential budgeting skills)
Supported Volunteering (meaningful use of time in a supported environment)
Recovery College (courses aimed at supporting/improving emotional & mental wellbeing) Benefits Advice
Benefits Advice
1 to 1 Budgeting
From the list below tell us why you would like to take part in a placement within Link Logs?
To learn new skills
To use existing skills
To gain work experience
For structure and routine
To make new friends & build community
Referral agency placement
Other
From time to time we would like to contact you with details of other news and services we provide. If you consent to us contacting you for this purpose, please tick to say how you would like us to contact you (you may tick more than one option):
Yes
No
Fruits List
Mango
Papaya
Apple
Orange
FSM/Pupil premium
Yes
No
Full name
Empty Answer Choice
Empty Answer Choice
Empty Answer Choice
Empty Answer Choice
Full-time or part-time
Full-time
Part-time
Funder
Brook
Westminster Foundation
Canary Wharf
Funder Type
Contracts
Grants
Trusts & Foundations
Funding stream
Camden Giving
Coldplay
Core
Criseren
Digital Project
Foux Foundation
Garfield and Weston
H&F unrestricted
London Funders
Mrs Smith & Mount Trust
National Lottery
Quentin Blake
Roden
Southwark Council
The Funding Network
The Royal Warrant Holders Charity Fund
Thierry Noir
TJH Foundation
Two Magpies
UNRESTRICTED - Hackney
GDPR Consent
Yes
No
GDPR consent to store data
Yes
No
GDPR permission box (can we contact you again about similar events)
Yes
No
GDPR special category: do you give consent to share these additional pieces of information
Religion
Ethnicity
Long term health condiiton or disability
Sexual Orientation
Trade Union
GDPR Statement; Personal information is used solely for use in participating in our Saturday 'On the Ball' Programme. We will keep in touch via SMS messages and / or telephone about other Communities First Foundation activities and opportunities the above
Yes
No
gender
Male
Female
Transgender
Gender neutral
Non-binary
Agender
Pangender
Other
Choose not to disclose
Gender
Male
Female
Prefer not to say
Gender
Male
Female
Prefer to describe
Gender
Male
Female
Transgender
Gender
Neutral
Non-binary
Agender
Pangender
Other
Choose not to disclose
Gender
Male
Female
Non-Binary
Prefer Not to Say
Gender
Male
Female
Others
Gender
Female
Male
Prefer not to say
Gender
M
F
Prefer not to say
Gender
Male
Female
Gender Fluid
Non Binary
Prefer not to say
Gender
Male
Female
Other
Gender
male
female
others
prefer not say
Gender
Male
Female
Other
Gender
Male
Female
Other
Prefer not to say
Gender
Male
Female
Others
Empty Answer Choice
Gender
Female
Male
Gender
Male
Female
Transgender
Gender neutral
Non-Binary
Agender
Pangender
Other
Prefer not to say
Gender
Male
Female
Non-binary
Other
Prefer not to say
Gender
Male
Female
Other
Gender
Male
Female
Other
Gender
Male
Female
Prefer not to say
Gender
Male (including trans male)
Female (including trans female)
Non-binary
Prefer not to say
Other
Gender
Male
Female
Trasgender
Prefer not to say
Gender
Male
Female
Prefer not say
Gender
Male
Female
Transgender
Gender
Female
Male
Nonbinary
Other
Prefer not to say
Gender
Male
Female
Others
Gender
Female
Male
Transgender
Non-Binary
Prefer not to say
Gender
Male
Female
Gender
Male
Female
Gender
Male
Female
Gender
Female
Male
Other
Gender
White
Black
Gender
Female
Male
Prefer not to say
Gender
Male
Female
Gender
Female
Male
Prefer not to say
Gender
Male
Female
Gender.
Male
Female
Transgender
Intersex
Other
Undisclosed/Prefer not to say
Non-binary, genderfluid
Gender*
Male
Female
Other
Prefer not to say
Gender (3 options)
Female
Male
Other
Gender (3 Options II)
Man
Woman
Other
Gender (8)
masculine
feminine
agender
transgender
pangender
genderqueer
androgynous
Prefer not to say
Gender Identity
Male
Female
Other
Prefer not to say
Gender Identity
Male (including trans male)
Female (including trans female)
Other Gender Identity
Not Disclosed
Non-binary
Gender same as assigned at birth
Yes
No
Gender Same as Birth
Yes
No
Prefer not to say
Gender-test
Male
Female
General academic ability
High
Above
Average
Below
Low
Genre
Adventure
Comedy
Romance
Thriller
Sci-fi
fantasy
Genres
Adventures
Fantasy
Fantasy Drama
Romance
Sci-Fi
Thriller
Geographical Site
Regensburg
Timisoara
Toulouse
Geographic scope
Borough
Pan London
National
G) I can remain calm when facing difficulties because I can rely on my coping abilities.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Given photo consent
Only for photos that DON'T identify them
Yes, for photos that include their face/identifying features
Yes, to be used in social media, website and digital comms
Yes, to be used in training, presentations, reports and press releases
Yes, to be used in printed campaign materials
No photo consent given
GP Surgery
Dinas Lane Medical Centre
Hollies Medical Centre
Prescott Medical Centre
Empty Answer Choice
Grade
1
2
3
4
5
6
7
8
9
10
11
12
Group
Yes
No
Group Agreement
Yes
No
G) The stress of not having enough food for me/us is harming my/our social, mental and physical health (eg including impacting on child development and mental health)
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Has allergies
Yes
No
Unknown
Has Learning difficulties?’
Yes
No
Suspected
Has mental health issues?
Yes
No
Unknown
Has multi-agency discussion taken place re referral?
Yes
No
Has physical health issues?
Yes
No
Unknown
Has taken parent education course before
Yes
No
Has the child been a victim of a crime in the last 12 months? Please say yes if you or someone in the professional network is aware they have been a victim, even if the child has not reported it to the police.
Yes
No
Has the child been a victim of serious violence in the last 12 months? Serious violence is defined as any drug, robbery or violence against the person offence that has a seriousness score of five of more. Please say yes even if they have not reported it to the police.
Yes
No
Has the child ever been arrested for a serious violence offence?
Yes
No
Has the child ever been a victim of a crime?
Yes
No
Unknown
Has the child ever been a victim of serious violence?
Yes
No
Unknown
Has the child ever been a victim of serious youth violence?
Yes
No
Has the child ever been known to early help or children's social care?
Yes
No
Unknown
Has the child ever been on Intensive Supervision and Surveillance (ISS) bail or order?
Yes
No
Has the child ever been remanded or sentenced to custody?
Yes, remanded (custody or local authority accommodation)
Yes, sentenced
Yes, both remanded and sentenced
Has the child ever had any missing episodes?
Yes
No
Has the child ever witnessed serious violence?
Yes
No
Has the child moved educational establishment in last 3 months
Yes
No
Has the child moved educational establishment in the last 12 months
Yes
No
Has the client consented to this referral?
Yes
No
Has the family given consent for this referral?
Yes
No
Has the family given consent for this referral?
Yes
No
Has the Lead Guide (or other) discussed the child with the professional network?
Yes
No
Has there been a change in who is living in the household in the last 12 months?
Yes
No
Has there been a significant bereavement in the child’s life?
Yes
No
Has there been concerns around accommodation stability or suitability in the last 12 months?
Yes
No
Has there been concerns around domestic abuse?
Yes
No
Unknown
Has there been concerns around domestic abuse in the last 12 months? This could include the child being the perpetrator or the victim, or seeing, hearing, or otherwise experiencing the effects of the abuse of relatives. Abuse could be physical, sexual, psychological, emotional or economic, including violent, threatening, controlling or coercive behaviour.
Yes
No
Unknown
Has your income decreased due to Covid-19?
Yes
No
Has your name been placed on a list of people barred from working with children or vulnerable adults?
Yes
No
Have there been incidents or indicators of self-harm or suicidal thoughts/behaviours in the last 12 months?
Yes
No
Have they a disability
Physical disability
Learning disability
Have they a medical condition
Yes
No
Have they been a victim of serious youth violence (in the last 12 months)
Yes
No
Have they ever been open to Youth Justice?
Yes, currently open
Yes, previously open
No
Have they had both their COVID vaccinations?
Yes
No
Have you and/or your partner ever been imprisoned?
Yes
No
Prefer not to say
Have you been prescribed any medication related to the above?
Yes
No
Have you ever accessed the Foodbank?
Yes
No
Have you ever been informed you child has been held at school or with another agency?
Yes
No
Have you ever considered pursuing advanced education (a bachelor’s/foundation/undergraduate degree) or a skill set beyond your current level of education - eg designer, special education, art/music?
Yes
No
Have you ever had a severe reaction to a bee or wasp sting?
Yes
No
Have you had a tetanus injection?
Yes
No
Have you had your COVID -19 vaccination?
Yes
No
Have you informed your GP that you are self-referring to ABF?
Yes
No
Have you or your family ever received a grant from Buttle UK?
Yes
No
Have you previously been involved with this campaign?
Yes
No
Not Sure
Have you previously undertaken a Goldstar Programme?
Yes
No
Have you received/been assessed for any Learning Difficulties such as /dyslexia / dyscalculia
Learning Difficulties
Dyslexia
Dyscalculia
Other
Have you used our services before?
Yes
No
Health and safety documents completed by SWT
Yes
No
Health and safety documents provided to CEH
Yes
No
Health condition
Healthy
Temporarily healthy
Temporarily ill
Ill
Chronically ill
Temporarily disabled
Disabled
Other
Prefer not to say
Not applicable
Health condition or disability
Yes
No
Health: Do you have any challenges around your health and wellbeing that would be helpful for us to know as we seek to support you?
Physical disability including hearing, speech, etc
Learning disability
Mental/Emotional wellbeing
Literacy difficulties
Other
No Disability
Health Issues
No
Yes
Health status
Not Recorded
Mental Health issues
Disability
Addiction
Other
Heard about course
Flyers/announcments
Friend/relative
Internet search
Newspaper/radio
Referral
Other
Hierarchical level
Option 1
Option 2
Highest Level of Education
Adult Literacy
College
No formal education
Post-primary, Vocational
Primary
Secondary
University
Highest Qualification
Entry level 1-3
GCSE
BTEC
T-Levels
A-level
Undergraduate degree
Postgraduate degree e.g. Masters
No qualifications
History of domestic violence
No
Yes
History of missing episodes
No
Yes
History of working with early help?
No
Yes
hostel
ENGLISH
INDIAN
FRENCH
GERMAN
Hostel of care
1
Empty Answer Choice
Empty Answer Choice
Empty Answer Choice
Host Prison
Kamiti Maximum
Kiambu Medium
Lang'ata Women
Machakos Main
Machakos Women
Murang'a Main
Murang'a Women
Nairobi Remand
Nairobi Medium
Naivasha Maximum
Naivasha Medium
Naivasha Women
Nakuru Women
Nyeri Maximum
Nyeri Medium
Nyeri Women
Thika Main
Thika Women
Other
Hotel
Castle Bromwich - Travelodge
Collections - Hagley Road
IBIS - Bordersley Green
IBIS- Hagley Road
IBIS- Irving Street
Park Inn - Walsall
Ramada - Solihull
Ramada - Sutton Coldfield
Rowton
Hours of support or training offered
1 to 5
6 to 10
11 to 15
16 to 20
20+
Household characteristics
One person household
One family household: couple
One family household: lone parent
Two or more unrelated adults
Multi-family household
Household income (per year)
Under £5000
£5000-£10,000
£10,000-£20,000
£20,000-£45,000
Over £45,000
Household size
1
2
3
4+
Household's Supply
Loo roll
Normal wet-wipes
Twipes
Housing Status
Homeowner
Rental: private tenant
Rental: housing association tenant
Temporary accommodation
Supported living
Housing: which of the following apply to you?
Council tenant
Housing Association
Owner occupier
Living with family
Living with friends
Private landlord
Other(specify)
How did this employer hear about Moving On Up
Access UK
Action West London
Brent Works
BTEG
College of North West London
HS2
Job Centre Plus - Brent
Making The Leap
PLIAS
Quintain
How did you get to know about Justice Defenders' legal services?
Awareness Sessions
Court
Posters
Other
How did you hear about our project *
Instagram
WhatsApp
Mentor/Organisation
Friends
Family
How did you hear about our services?
Family
Awareness Sessions
Friends
Paralegal
TV
Other
How did you hear about RESET?
Foodbank
Open Door
Friend/Family
Other
How did you hear about services at the community legal office
TV
Family
Friends
Radio
Internet
Flyers/IEC materials
Paralegal
Awareness session
Prison
Court
Community outreach
JD staff
How did you hear about us?
Publication or Newspaper
Social Media
Word of Mouth
Used the service before
Our Website
Leaflet or Poster
MP or Councillor
Another organisation
Event
How did you hear about Vintage Vibes (referrer options)
Previously Referrered
Word of Mouth
Internet Search
Internal Referral - LifeCare or Space
NHS Networks
Promotional Flyer
Vintage Vibes Stall/Event
Other
How did you hear about Vintage Vibes (volunteer options)
Befriending Networks
Online search
Social media (Facebook, Instagram, other)
Vintage Vibes Flyer
Vintage Vibes Stall/Event
Vintage Vibes Campaign
Vintage Vibes volunteer
Volunteer Edinburgh
University Event
Other
How do you communicate
Makaton/Sign Language
Pecs
Preverbal
Verbal
Other
How do you currently spend your time?
School / Sixth Form / College
Not in Education or Employment
Working
Apprenticeship
Other
How do you greet?
Hi
Hello
Hey
Sup up
How do you know the person who requires support?
Family
Fire Service
Friend
Credit Union
Housing Association
KMBC
Police
Faith Organisation
Voluntary Sector Organisation
Leisure Service
How far away do you live?
Under 1 mile away
1-3 miles away
3-5 miles away
How heard about RCH
External professional/referral Personal
invite from team
School
Self-Referral via Health Professional
Social media
Word of mouth
Written advert (poster/letter)
How likely are you to invite other Christian sportspeople you know to training courses like this?
Not likely at all
Not likely
Maybe
Likely
Very likely
How likely are you to recommend the Mental Health First Aid Wales training to others?
1 - Poor
2
3
4
5 - Excellent
How likely do you think it is it that your mental health would have improved without the involvement of Advance Brighter Futures
Very Unlikely
Unlikely
Likely
Very Likely
How long have you been claiming benefit(s)?
N/A
0-6 months
6-12 months
More than 1 year
More than 5 years
How many dependents do they have
English
French
German
Indian
How many enterprises do you currently own? Enumerator _Rank the top 3 enterprises only provide their detail in the next questions
1
2
3
How much of the improvement to your mental health is a result of contribution from family, friends and other organisations?
Very Little
Little
A Lot
Almost All
How often are you able to volunteer?
Weekly
Fortnightly
Monthly
How often do you read or share books with your baby or child
never
Once or twice a month
once or twice a week
Most days
How often to you do an online shop or surf the internet etc
Never
Occasionally
Regularly
How old are you?
16
17
18
How would you characterize your organisation?
Startup
Established
Expanding
Struggling
Merging
Dissolving
Other
How would you describe your caring responsibilities?
Child(ren) under 18
An older person
A person with a disability
None
Prefer not to say
How would you describe your current mental health?
Struggling
Up & down
Feeling pretty good
Really positive
How would you describe your Sexual Orientation?
Bisexual
Gay
Heterosexual
Lesbian
Prefer not to say
Other (please specify)
How would you like us to respond?
Phone
Email
How would you prefer us to contact you?
Mobile
Work phone
Home phone
Email
How would you rate the range and quality of stock provided at the social supermarket? *(e.g. fruit and vegetables, bread and dairy products as well as ambient foods).
Excellent
Good
Neither/Nor
Poor
Very Poor
How would you rate the reasonableness/ affordability of the joining/ ongoing membership fees charged by the social supermarket?
Excellent
Good
Neither/Nor
Poor
Very Poor
How You Heard About Us?
Word of Mouth
Online
How YP consent to store data was gained?
Verbal
On new Young Person form
Hub representation
Yes
No
H) When I am confronted with a problem, I can usually find several solutions.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
I accept your Data Protection Policy
Yes
I agree that should I be successful in this application, I will, if required, apply to the Disclosure & Barring Service/Disclosure Scotland for a Disclosure & Barring Certificate. I understand that should I fail to do so, or should the disclosure not be to the satisfaction of the company any offer of employment may be withdrawn or my employment terminated.
I agree
No
I agree to the Participant Data Policy: https://sport4life.org.uk/participant-data-policy/
Yes
No
I agree to the privacy policy and I am happy for Sport 4 Life to contact me. Our Privacy Policy can be found here [https://sport4life.org.uk/privacy-policy/]
Yes
I am 16 years or over
No
Yes
I am available for
One off events (e.g. Supermarket collections, Christmas box sorting, annual stocktake)
1-4 hours a week AM/PM on: Mon/Tues/Wed/Thurs/Fri
Full day(s) on: Mon/Tues/Wed/Thurs/Fri/Sat
Other:
I am happy to be contacted by Sport 4 Life UK and agree to the Privacy Policy: https://sport4life.org.uk/privacy-policy
Yes
I am happy to take part in this evaluation. I understand that this is an optional part of the programme and that my responses will be kept confidential.
Yes
No
I am interested in Vintage Vibes for...
Myself
Someone I know
I confirm that PLUS staff may act in accordance to the procedures outlined in this epilepsy care plan
Yes
No
I confirm that the above information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.
I confirm
No
Empty Answer Choice
Empty Answer Choice
I confirm that the above information is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.
I confirm
No
I confirm that the above instructions should be followed
Yes
No
I consent to my child’s image in photograph and video form being used by Explore Partnership CIC and Silly Fish Learning Ltd on their website and social media platforms.
Yes
No
I consent to my image in photograph and video form being used by TDCA on their website and social media platforms.
Yes
No
Identified Participant Aims
To participate in education
To gain a qualification
To engage in job-searching
To gain employment
To engage in life skills
To engage with the benefits system
To be business ready/start business
Other (please specify)
If Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Other Asian background
If Black, African, Caribbean or Black British
African
Caribbean
Prefer not to say
Other Black background
I feel connected to other members of the WG
Strongly Disagree
Moderately Disagree
Neither Agree/Disagree
Moderately Agree
Strongly Disagree
If Mixed or Multiple ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Prefer not to say
Other mixed background
If Other
Arab
Prefer not to say
Other ethnic group
If the child is currently on bail, is it police bail or court bail?
Police bail
Court bail
If the Referrer details are the same as the VIP or Next of Kin details, please tick the appropriate box:
VIP
Next of Kin
If they come to an event without it will they be ok?
Yes
No
If White
English
Welsh
Scottish
Northern Irish
Irish
British
Gypsy or Irish Traveller
Prefer not to say
Other white background
If yes, please indicate which type of impairment (s) applies to you.
Physical impairment (e.g. difficulty using arms or requiring a wheelchair or crutches)
Sensory Impairment, such as blind/visual impairment or deaf/hearing impairment
Mental health condition (e.g. depression or schizophrenia
Long standing illness, such as cancer, HIV, diabetes, chronic heart disease or epilepsy
Other (please specify)
Prefer not to say
If you are not working, how long have you been without work:
0-6 months
6-12 months
12-24 months
2-3 years
3+ years
If you are under 18 parent/guardian permission should needs to sign so that we can share this information with your tutor
Yes
If you interested in volunteering within the Community Employment Hubs please indicate below the role and service in which you would like to volunteer (you can be a volunteer in more than one role and in more than one location).
One-to-one support
Admin support
Refreshments
Meet and greet
IT support volunteer
If your child attends a nursery or school, what is the name of the school or nursery?
Cardinal Road
Crane Park Day Nursery
Edward Pauling Primary
Fairholme Primary
George's Preschool
Lindon Bennett
Little George's
Marjory Kinnon School
Once Upon a Time Day Nursery (Blair Athol)
Once Upon a Time Day Nursery (Feltham Hill)
Rose Park Day Nursery
Space Studio West London
St Albans Day Nursery
St George's Day Nursery
St Richards PreSchool
Southville Primary School
Tiny Toez Pre-School
St Richards CoE
West Thames College
Harvard Park Day Nursery
South Bedfont Playgroup
Small Steps Day Nursery and Pre School
Victoria Juniors
Oak Hill Academy
Oriel Academy
Reach Academy Feltham
Rivers Academy
Springwest Academy
St Lawrence RC Primary
Logic Studio School
Woodbridge Park
Home schooled
`Not in education
Other
If your child goes to Reach Academy please click here to indicate that you are happy for us to access your information from the school's database.
Yes
If you were stung, would we need to call the emergency services?
Yes
No
If you were unlucky to be stung by a bee, wasp or nettles would you be happy for us to use a herbal bite treatment?
Yes
No
I give consent for the personal details provided by me, regarding my family, to be held by PLUS (Forth Valley)
Yes
No
I give Ekota Academy permission to record the image and/or voice and/or words of myself (the young person named above) / my child and grant Ekota Academy all rights to add the still or moving images and any accompanying words to the Library Stock of Ekota Academy and to use them in any medium for its educational, promotional or other work that supports the mission of the charity.
Yes
No
I give permission for the Rendezvous to contact me by:
Mobile
Social Media
Email
Home no
I give permission for the Rendezvous to hold my personal details
Yes
I give permission for the Rendezvous to record and store information about the work that I do with the Rendezvous team.
Yes
No
I give permission for you to take images and video of me whilst engaging with the Rendezvous for the purpose of recording activities and promoting the centre.
Yes
No
I grant CASPA permission for any reproductions or adaptations of the images for the purpose of the newsletter, fundraising, funding applications, marketing materials, news and events publications and Social Media (i.e. Facebook, Twitter & Instagram) both online and printed.
Yes
No
I grant CASPA permission to use images/recordings resulting from the photography/video filming and informal interview
Yes
No
I have read and agree to the above.
Yes
No
I have read, and agree to the Guidelines for BYW Activities
Yes
No
I have read and understood the information above and am happy for staff at Reach Children’s Hub to access my personal information from Reach Academy’s data base. I understand the staff have a duty of care and can pass information without my permission
Yes
No
I) If I have a problem, I can usually think of something to do
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
I left the meeting with clear next steps to be completed before the next meeting
Strongly Disagree
Moderately Disagree
Neither Agree/Disagree
Moderately Agree
Strongly Agree
I'm happy for North East Wales ACL Partnership to contact me about new courses
By text
By phone
By email
No
Immigration status
UK National/British Citizen
EU National
Full Refugee Status
Indefinite leave to remain
Exceptional/Discretionary leave to remain
Humanitarian Protection
Asylum seeker
Other
Immigration Status
Asylum Seeker
Asylum Seeker - age disputed
Discretionary Leave/Limited Leave to Remain
Humanitarian Protection
Indefinite leave to remain
Overstayer
Refugee Status
Refugee Status - Family Reunion
Spouse Visa
Visitor Visa
Undocumented
UASC
Unsure-don't know
Other
Include in Annual Report
Yes
No
Income:
Pupil Premium
FSM
2yo Funding
Other
Incubator cohort
2016-18 [Demand Reduction]
2017-19 [16-25s]
2018-20 [BAME]
2019-21 [Health Wellbeing]
2020 [Housing]
2021 [Employability]
2021 [Alternative]
India
English
French
German
Portuguese
Industry Preference
Agricultural, environment and Animal Care
Business, Administration and Law
Construction
Creative Media and Arts
Customer Service and Retail
Digital and ICT
Energy
Engineering and Electrical
Financial Services
Hair and Beauty
Health and Wellbeing
Hospitality, Travel and Catering
Manufacturing, Processing and Logistics
Marine
Public Services
Science and R&D
Sports and Fitness
Vehicles and Transportation
Education and Childcare
Mathematics
Initial Contact
YP referral and/or follow up
Advice or information
Other
In receipt of benefits
Yes
No
Insurance
Yes
No
Interpreting REQ?
Yes
No
Intervention type
Aspirations and confidence
Engagement and motivation
Securing post 16 destination
Securing post 18 destination
In the past few weeks, were you any of the following?
Full-time education
Paid work full-time
Paid work part-time
Self-employed
Out of work, registered unemployed and actively seeking work
Out of work, registered unemployed but not actively seeking work
Permanently sick/disabled
Not working for domestic reasons
Retired
None of the above - please specify
Involved in community youth services?
No
Yes
In your opinion is the adult at risk of serious harm?
Yes
No
Not sure
In your opinion is the client in at risk to others?
Yes
No
Not sure
In your opinion is the client in need of protection?
Yes
No
Not sure
Is an interpreter required
Yes
No
Is English the first language that you speak at home?
Yes
No
Is English your child's first language?
Yes
No
Empty Answer Choice
Empty Answer Choice
Is English your first langauge?
Yes
No
Empty Answer Choice
Empty Answer Choice
Is English your first language?
Yes
No
Prefer not to say
Is English your first language?
Yes
No
Undeclared
Is it ok to email?
Yes
No
Is it ok to leave message?
Yes
No
Is it ok to text?
Yes
No
Is it safe for the child/YP to get out of their chair
Yes
No
Is NIHE your landlord?
Yes
No
Is the 2nd dose the same medication, dose and delivery as the 1st
Yes
No
Is the 2nd dose the same medication, dose and delivery as the 1st
Yes
No
Is the chair used all the time of just for longer distances
All the time
Just for longer distances
Is the child currently on bail?
Yes
No
Is the child persistently or severely absent from school?
Yes, severely absent (50% and below)
Yes, persistently absent (90% and below)
No
Unknown
Is the child tube fed?
Yes
No
Is the gender you identify with the same as your sex registered at birth?
Yes
No (write in gender identity)
Prefer not to say
Is the GP aware of this referral
Yes
No
Is the individual currently under the care of a primary or secondary mental health team?
Yes
No
Is the individual happy to work in a group?
Yes
No
Is the individual motivated to working towards goals?
Yes
No
Is the individual over the age of 18
Yes
No
Is their Gender identity the same as assigned at birth
Yes
No
Prefer not to say
IS THE PERSON OF CONCERN AN ADULT OR CHILD? (i.e. are they over or under 18?)
Adult
Child
Is there anything that you would like us to know about your experience at school or education generally
Yes
No
Is there are support you might need to enable you to volunteer with us?
Yes
No
Is there a welfare guardianship order in place for the young person?
Yes - Guardianship order in place
No - Guardianship order not in place
Not yet - currently in progress
Empty Answer Choice
Is there a welfare or financial guardian in place
Yes
No
Is there concern about the child's use of substances?
Yes
No
Is there either a current concern or known history of alcohol/substance misuse?
Yes
No
Is the young person 18 years or older?
Yes
No
Is the young person on a CIN or CP Plan?
Yes: CIN
Yes: CP
No
Is this an Incident, Concern or Disclosure? ( Incident = It is happening or has happened Concern = There is a likelihood it will happen Disclosure = Someone has told you about an event)
Incident
Concern
Current Disclosure
Historic Disclosure
Is this number the same as your emergency contact [Please complete details below]
Yes
No
Is this young person on a current court order or Out Of Court Disposal?
Yes
No
Is young person on medicine?
Yes
No
Is your service continuing after this referral?
Yes
No
IT job type - please specify
Data Architect
IT Analyst
IT Manager
IT Officer
IT Support
Other (Please specify) - Bl Assistant
Other (Please specify) - Business Analyst
Other (Please specify) - Business Process and Sr Applications Support
Other (Please specify) - BUsiness Process/Application Support
Other (Please specify) - Cloud Engineer
Other (Please specify) - Cloud Operations
Other (Please specify) - IT Coordinator
Other (Please specify) - IT Support Supervisor
Other (Please specify) - Not involved
Other (Please specify) - Specialist
Other (Please specify) - Technical Lead
Product Owner
Project Manager
Software Developer
System Architect
Systems Administrator
Systems Architect
Systems Engineer
I understand how it will be stored (digitally on lamplight & hard copy locked in a locked cabinet)
Yes
I understand how long it will be kept for (5 years after the last contact, then destroyed)
Yes
I understand that I am entitled to view any information stored by PLUS regarding myself/my child/my children/ my family. I can request this by sending a written and signed letter to PLUS.
Yes
No
I understand that I have a right to withdraw these permissions at any time.
Yes
I understand that I have the right to withdraw consent at any time and can request that my details are deleted and destroyed. I can do this by sending a written and signed request to PLUS.
Yes
No
I understand that the Rendezvous will not use images or video in the public domain where I am the main subject without my permission
Yes
No
I understand why the Rendezvous needs this information
Yes
I will inform the coaches of any important changes to this participants health, medication or needs and any changes to the participants emergency contacts and phone numbers. In the event of illness or injury, If the participant should require emergency h
Yes
No
I would be interested in helping regularly in the following area(s)
Warehouse (Foodbank & Social Supermarket)
Supermarket collections
Fundraising/events
Deliveries or collections (using own vehicle)
Maintenance/DIY
Assisting in the office
Wellbeing/befriending
ESOL (English Classes)
Family activities (incl. Tiny Tots, After Schools, Youth)
Other specialist skills: please specify
I would prefer to be contacted by:
Mobile
Social Media
Email
Home no
J) No matter what comes my way, I’m usually able to handle it.
Strongly Agree
Agree
Neither Agree/Disagree
Disagree
Strongly Disagree
Job Title (Role)
Finance
COO - Chief Operating Officer
Chief Executive
IT & Systems
Changemaker
Key issued to CEH
Yes
No
Known allergies
Yes
No
Known Risks: Please tick if any of the following applies to the client
The client is posing a risk to self or other (e.g. staff/volunteers)
The client requires monitoring due to vulnerability
The client is an adult at risk of harm
The client is an adult in need of protection
The client is a vulnerable adult (i.e. with capacity issues)
None of the above
LAC
Yes
No
Language
English
Hindi
French
German
Language
English
Hindi
French
German
Language Spoken
Afrikaans
Albanian
Amharic
Arabic
Armenian
Bengali
Byelorussian
Burmese
Bulgarian
Czech
Chinese
Croatian
Danish
Dari
Dzongkha
Dutch
English
Esperanto
Estonian
Faroese
Farsi
Finnish
French
German
Greek
Hebrew
Hindi
Hungarian
Icelandic
Indonesian
Italian
Japanese
Korean
Kurdish Kumanji
Kurdish Sorani
Laotian
Latvian
Lithuanian
Norwegian
Macedonian
Malay
Pashto
Polish
Portuguese
Punjabi
Romanian
Russian
Serbian
Slovak
Slovenian
Somali
Spanish
Swedish
Swahili
Ukrainian
Urdu
Uzbek
Tamil
Thai
Tigrinya
Turkish
Turkmen
Vietnamese
Welsh
Lawful basis for processing their Personal Data
Consent
Contract
Legal obligation
Vital interests
Public task
Legitimate interests
Lead Client (Deal/Retention Decision maker)
Yes
No
Lead / Sole Trainer
Caroline Kerr
Cathy Murphy
Christine Chapman
Claire Giles
Deb Birch
Diane Laird
Gail Allan
Helen Gamble
Jean Deacon
Jen Rivett
Jo Anderson
Jo Tickle
Kathy Peto
Lisa Phillips
Liz Davies
Luce Carter
Lyndsay Harrison
Maggie Fisher
Mandy Habgood
Mary Duggan
Mary Taylor
Michelle Tucker
Moyra Adams
Peter Leonard
Rachel Walding
Rosie Hatton
Rowen Smith
Sara Bright
Sara Wiggins
Sarah Bojakowski
Sarah Darton
Sharon Lawton
Verity Lowe
Vicky Knight
Yvonne Hayes
Learning Difficulties
Yes
No
Legal/insurance job type - please specify
Claims
Insurance - corporate/company
Insurance - marine/claims
Legal Associate
Legal Counsel
Other: Regulatory Compliance
Regulatory Compliance
Legal Status
CIO (Charitable Incorporated Organisation)
Registered Charity
Social Enterprise
Other
Letter of Understanding
Yes
No
Level::
C-Suite
Vice President
Head of
Director
Lead
Senior Manager
Manager
Executive
Level of prison security
Medium
Maximum
Lions Kids
Livestock Herders
Students
List Barrier fields
Digitally excluded – few skills
Digitally excluded – no equipment
Digitally exluded – no service poor coverage
Financial – travel costs
Financial – clothing
Financial – fuel poverty
Financial – food charity
Financial – lack of access to affordable child
Vulnerable Adult – mental ill health
Vulnerable Adult – anxiety/depression
Vulnerable Adult – other long term illness
Learning Disability – cognitive impairment
Learning Disability – non neurotypical
Learning Disabilty – sensory impairment
English not first language
Substance misuse
Ex offender
Care leaver
Ex Military
Anger change
Difficulty forming relationships
Poor Communication Skills
Lived experiences
Estrangement
Care experienced
Young carer
Kinship care
Domestic abuse
Homelessness
Living situation
Living independently
Family home
With other family member
With friends
Social services
House share
Supported accommodation
Sofa surfing
Rough sleeper
Local Authority
Buckinghamshire
Manchester
Local Authority Area
Mendip
Sedgemoor
Somerset West and Taunton
South Somerset
Local status
Local resident
Employed in this area
Just visiting
Location
International
National
West Midlands
Birmingham wide
Alum Rock
City Centre
Digbeth
Druids Heath
Edgbaston
Erdington
Halesowen
Hodgehill
Kings Heath
Lea Hall
Longbridge
Naseby
Nechells
Newtown
Northfield
Perry Barr
Sandwell
Tipton
Walsall
Witton Lodge
Wolverhampton
Yardley
Location
Women's Aid Croydon
Migrant Help UK
Hestia
Location
Gillingham
Sherborne
locationData.country
England
Scotland
Northern Ireland
Wales
locationData.region
West Midlands
London
North West
South East
Yorkshire and The Humber
North East
East of England
South West
East Midlands
Location on Discord
Channel
Text
Chat
Other
Location Type
Business
Charities
CIC
Colleges
Community
Other
Police
Refugee
Schools
University
Long term Health Conditions
Yes
No
Looked after child
Yes - currently
Yes - previously
No
Magistrate courts
Bulera Magistrate court
Butayunjuja Magistrate court
Kakindu Magistrate court
Mityana Magistrate court
kagadi Magistrate court
Kakumiro Magistrate court
Kibaale Magistrate court
Muhoro Magistrate court
Nyalweyo Magistrate court
Mabaale Magistrate court
Bkukumira Magistrate court
Kasambya Magistrate court
Kassana Magistrate court
Kiganda Magistrate court
Mubende Magistrate court
Myanzi Magistrate court
Kyambogo Magistrate court
Luzira Magistrate court
Nakawa Magistrate court
Ntinda Magistrate court
Goma Magistrate court
Kasawo Magistrate court
Koome Islands Magistrate court
Mukono Magistrate court
Nakifuma Magistrate court
Nakisunga Magistrate court
Nabweru Magistrate court
Kawempe Magistrate court
Matugga Magistrate court
Mengo Magistrate court
Kasubi Magistrate court
Nateete Magistrate court
Ndeeba Magistrate court
Rubaga Magistrate court
Bombo Magistrate court
Luwero Magistrate court
Nakaseke Magistrate court
Ngoma Magistrate court
Semuto Magistrate court
Wobulenzi Magistrate court
Zirobwe Magistrate court
Gaba Magistrate court
Kabalagala Magistrate court
Makindye Magistrate court
Namuwongo Magistrate court
Zaana Magistrate court
Makindye Chief Magistrate court
Buganda Road Chief Magistrate Court
LDC Magistrate court
Entebbe Chief Magistrate court
Entebbe Magistrate court
Nkumba Magistrate court
Kajjansi Chief Magistrate court
Kajjansi Magistrate court
Kasanje Magistrate court
Kibaale Chief Magistrate court
Mityana Chief Magistrate Court
Mpigi Chief Magistrate court
Bujuuko Magistrate court
Buwamba Magistrate court
Kayabwe Magistrate court
Mpigi Magistrate court
Nsangi Magistrate court
Wakiso Chief Magistrate court
Kakiri Magistrate court
Nansana Magistrate court
Wakiso Magistrate court
Mainstream?
Mainstream
Non-Mainstream
Main teacher or Rotator
Main teacher
Rotator
Manual or electric wheelchair
Manual
Electric
Manylwch pa wasanaeth yr hoffech ei gyrchu isod - darllenwch y meini prawf cymhwysedd ar ein hamserlen gwasanaeth yn gyntaf (Dewiswch gynifer o opsiynau ag y dymunwch
Dewiswch PRAMS (Gwasanaethau wedi'u hanelu at rieni a rhieni beichiog)
Therapïau Siarad (sesiynau un i un)
Sesiynau grŵp (fel 'Pump i Ffynnu')
Cyrsiau (fel Ymwybyddiaeth Iechyd Meddwl
Byw hyfforddi bywyd
Taith gerdded Byw
Celf/crefft Byw
Rhandir Byw
Ddim yn siŵr
Marital status
Divorced
Married
Other
Separated
Single
Widow
Marital Status
Single
In a relationship
In partnership
Divorced
Married
Separated
Widowed
Other
Not applicable
Marital Status
Divorcee
Married
Single
Committed
Marital Status
Single
Married
In a Civil Partnership
Separated
Divorced
Widowed
Prefer not to say
Marketing Preference
Yes, I’d like to receive occasional marketing messages
No, do not send me any marketing messages
Match Preferences
Female Volunteer
Male Volunteer
No Preference
Maths and English GCSE (select whichever or both that they do not have)
Does not have English GCSE
Does not have Maths GCSE
Support not needed - has both English & Maths GCSE
MCQ tracker 1
1
2
Media Consent: I consent to being photographed/filmed for marketing purposes. View our policy here - https://sport4life.org.uk/privacy-policy/
Yes
No
Media & Publicity permission
Yes
No
Medical Condition
Yes
No
Medical Practitioner consent received
Yes
No
Meeting category
Conference
Symposium
Workshop
Meet Regularly?
Yes
No
Membership of a Big Local Area
From a Big Local Area
Not from a Big Local Area
Mentoring
One to One
Training in-house
External Training
Meeting
Supervision
ESTEEM related Community Event
ESTEEM Event
Method of feeding
Bolus
Pump
M/F
M
F
Middle office job type - please specify
Internal Pricing
Other (Please specify)
Other (Please specify) - Accounting
Other (Please specify) - Admin plus many other depts.
Other (Please specify) - Business Analyst
Other (Please specify) - cadet training
Other (Please specify) - Compliance
Other (Please specify) - CUSTOMER RELATIONS
Other (Please specify) - Department Manager
Other (Please specify) - Documentation
Other (Please specify) - Global Mobility
Other (Please specify) - Learning and Development
Other (Please specify) - Manager
Other (Please specify) - Manager Cargo Handling
Other (Please specify) - n/a
Other (Please specify) - NA
Other (Please specify) - None
Other (Please specify) - Operations
Other (Please specify) - Purchasing
Other (Please specify) - QHSE
Other (Please specify) - Regulatory Compliance
Other (Please specify) - Ship managment
Other (Please specify) - Supervising
Other (Please specify) - TECHNICAL PROCUREMENT
Other (Please specify) - Trainer
Other (Please specify) - TRAINING
Product Control
Mixed/Multi ethnic groups
White/Black Caribbean
White/Black African
White Asian
Other
Mode of Delivery
Virtual
Face-to-face
Module
10 Signs
Delving Deeper
Inclusive
Pornography
Intimate Image Abuse
CPD
Workplace
Modules they are supporting
Commercial Law
Contract Law
Criminal Law
Equity and Trust
Evidence Law
International Protection Of Human Rights
Jurisprudence
Labour Law from a Global perspective
Law of Tort
Legal System and Methods
Property Law
Public Law
Monitor and gather more information
Yes
No, already have information information
Empty Answer Choice
Empty Answer Choice
Monthly DD Donor
Yes
No
Monthly DD Gift Aid
Yes
No
Movie audience
U
PG
12A
18+
Must the child/YP always wear it?
Yes
No
My child in an group photo
Yes
No
Name
English
French
German
Indian
Name
Empty Answer Choice
Name
1
2
3
4
Name of Agency
Carer's Relief
Anchor Support
Flight Project
Clarion Housing
Lifeways
Symbols
Seeability
Phoenix
Scotts Project Trust
Allerton
PCAS
Avenues
Choice Support
LMW Support
West Kent Housing
Achievetogether
KASBAH
Isay
Endurance Care
Other
Nationality
Afghan
Albanian
Algerian
American
Andorran
Angolan
Anguillan
Argentine
Armenian
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Belarusian
Belgian
Belizean
Beninese
Bermudian
Bhutanese
Bolivian
Botswanan
Brazilian
British
British Virgin Islander
Bruneian
Bulgarian
Burkinan
Burmese
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Cayman Islander
Central African
Chadian
Chilean
Chinese
Citizen of Antigua and Barbuda
Citizen of Bosnia and Herzegovina
Citizen of the Dominican Republic
Citizen of Guinea-Bissau
Citizen of Kiribati
Citizen of Seychelles
Citizen of Vanuatu
Colombian
Comoran
Congolese (Congo)
Congolese (DRC)
Cook Islander
Costa Rican
Croatian
Cuban
Cymraes
Cymro
Cypriot
Czech
Danish
Djiboutian
Dominican
Dutch
East Timorese
Ecuadorean
Egyptian
Emirati
English
Equatorial Guinean
Eritrean
Estonian
Ethiopian
Faroese
Fijian
Filipino
Finnish
French
Gabonese
Gambian
Georgian
German
Ghanaian
Gibraltarian
Greek
Greenlandic
Grenadian
Guamanian
Guatemalan
Guinean
Guyanese
Haitian
Honduran
Hong Konger
Hungarian
Icelandic
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakh
Kenyan
Kittitian
Kosovan
Kuwaiti
Kyrgyz
Lao
Latvian
Lebanese
Liberian
Liberian
Liechtenstein citizen
Lithuanian
Luxembourger
Macanese
Macedonian
Malagasy
Malawian
Malaysian
Maldivian
Malian
Maltese
Marshallese
Martiniquais
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monegasque
Mongolian
Montenegrin
Montserratian
Moroccan
Mosotho
Mozambican
Namibian
Nauruan
Nepalese
New Zealander
Nicaraguan
Nigerian
Nigerien
Niuean
North Korean
Northern Irish
Norwegian
Omani
Pakistani
Palauan
Palestinian
Panamanian
Papua New Guinean
Paraguayan
Peruvian
Pitcairn Islander
Polish
Portuguese
Prydeinig
Puerto Rican
Qatari
Romanian
Russian
Rwandan
Salvadorean
Sammarinese
Samoan
Sao Tomean
Saudi Arabian
Scottish
Senegalese
Serbian
Sierra Leonean
Singaporean
Slovak
Slovenian
Solomon Islander
Somali
South African
South Korean
South Sudanese
Spanish
Sri Lankan
St Helenian
St Lucian
Stateless
Sudanese
Surinamese
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Togolese
Tongan
Trinidadian
Tristanian
Tunisian
Turkish
Turkmen
Turks and Caicos Islander
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbek
Vatican citizen
Vanuatu citizen
Venezuelan
Vietnamese
Vincentian
Wallisian
Welsh
Yemeni
Zambian
Zimbabwean
Nationality
TestCharacterstic
Nationality
American
European
Asian
Latin American
Nationality
British
Syrian
Norwegian
Indian
French
Portuguese
Nationality
Afghan
Albanian
Algerian
American
Andorran
Angolan
Anguillan
Citizen of Antigua and Barbuda
Argentine
Armenian
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Belarusian
Belgian
Belizean
Beninese
Bermudian
Bhutanese
Bolivian
Citizen of Bosnia and Herzegovina
Botswanan
Brazilian
British
British Virgin Islander
Bruneian
Bulgarian
Burkinan
Burmese
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Cayman Islander
Central African
Chadian
Chilean
Chinese
Colombian
Congolese (Congo)
Congolese (DRC)
Cook Islander
Costa Rican
Croatian
Cuban
Cypriot
Czech
Danish
Djiboutian
Dominican
Citizen of the Dominican Republic
Dutch
East Timorese
Ecuadorean
Egyptian
Emirati
English
Equatorial Guinean
Eritrean
Estonian
Ethiopian
Faroese
Fijian
Filipino
Finnish
French
Gabonese
Gambian
Georgian
German
German
Gibraltarian
Greek
Greenlandic
Grenadian
Guamanian
Guatemalan
Citizen of Guinea-Bissau
Guinean
Guyanese
Haitian
Honduran
Hong Konger
Hungarian
Icelandic
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakh
Kenyan
Kittitian
Citizen of Kiribati
Kosovan
Kurdish
Kuwaiti
Lao
Latvian
Lebanese
Liberian
Libyan
Liechtenstein citizen
Lithuanian
Luxembourger
Macanese
Macedonian
Malagasy
Marshallese
Nicaraguan
Nigerian
Northern Irish
Norwegian
Omani
Pakistani
Palauan
Palestinian
Papua New Guinean
Paraguayan
Peruvian
Polish
Portuguese
Puerto Rican
Qatari
Romanian
Russian
Rwandan
Salvadorean
Sammarinese
Samoan
Sao Tomean
Saudi Arabian
Scottish
Serbian
Citizen of Seychelles
Sierra Leonean
Singaporean
Slovak
Slovenian
Solomon Islander
Somali
South African
Spanish
Surinamese
Swazi
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Togolese
Tongan
Trinidadian
Tristanian
Tunisian
Turkish
Ukrainian
Uruguayan
Citizen of Vanuatu
Venezuelan
Vietnamese
Wallisian
Welsh
Zimbabwean
Malaysian
Maldivian
Malian
Maltese
Martiniquais
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Mongolian
Montenegrin
Montserratian
Moroccan
Mosotho
Mozambican
Namibian
Nauruan
Nepalese
New Zealander
North Korean
Panamanian
Senegalese
South Korean
South Sudanese
Sri Lankan
St Helenian
St Lucian
Stateless
Sudanese
Swedish
Turkmen
Ugandan
Uzbek
Vincentian
Yemeni
Zambian
Malawian
Nationality
Businesses
Native Language
Albanian
Arabic
Armenian
Aymara
Berber
Chichewa
Dutch
English
French
German
Greek
Guarani
Hindustani
Italian
Korean
Malay
Persian
Portuguese
Quechua
Romanian
Russian
Rwanda-Rundi
Serbo-Croatian
Somali
Sotho
Spanish
Standard Chinese
Swahili
Swati
Swedish
Tamil
Tigrinya
Tswana
Turkish
Venda
Xhosa
Nature of client
Litigant
Non litigant
Empty Answer Choice
Empty Answer Choice
Nature of contact
Enquiry
Newsletter Sign-up
Volunteer
Partnership
General Comment
Complaint
Media Enquiry
Personal Data Request
Nature of enquiry
Setting up a new group
Guidance and support
Training
Partnership working
Advice on practice
Advice on policy
Other
Nature of service provided
On-board training/support
Real time external training/support
Follow-up external training/support
NEET/EET Status on sign up
In Education (Full Time)
In Education (under 16 hours)
In Employment (under 16 hours)
NEET
NEET (11 to 16)
New Customer Type
Paying
Free Trial
New HubSpot Deal Activities
Prospects Met
Old Leads Contacted
Current Deals Contacted
Deals Advanced Forward
New or Returning Partner
New
Returning
New Service User
Yes
No
Next of Kin address
English
French
German
Indian
Next of Kin email
English
French
German
Indian
Next of Kin name
English
French
German
Indian
Next of Kin phone
English
French
German
Indian
Next steps interest
Apprenticeship
Summer Schools
University
Work experience
Nodwch yr holl ddulliau rydych chi'n hapus i ni eu defnyddio i gysylltu â chi (Dewiswch gynifer o opsiynau ag y dymunwch)
ffón
testun
Post Llais
llythyr
ebost
No Further Action (NFA)
No further action is required
No judgement, have you ever?
Been excluded or expelled from school/college?
Underachieved at GCSE or A-Level?
Been to a PRU?
Been arrested?
Been to prison?
Notify 1st next of kin in case of emergency?
Yes
No
Notify 2nd next of kin in case of emergency?
Yes
No
Not receiving funding
Yes
No
Number of female household member(s)
0
1
2
3
4
5
6
7
8
32
Number of male household member(s)
0
1
2
3
4
5
6
7
Offence Category
Abduction/kidnapping
Abortion/killing unborn child
Accessory after the fact to murder
Adultery
Affray
Aggravated defilement
Aiding escape
Aiding suicide
Arson
Assault occasioning grievous/actual bodily harm
Attempt to commit unnatural offence
Attempted abortion
Attempted arson
Attempted defilement
Attempted murder
Attempted rape
Attempted robbery
Attempted suicide
Being idle and didorderly/vagabond
Burglary/house breaking/breaking into building
Causing death by driving or obstruction
Child neglect
Child prostitution
Child stealing
Common assault
Common nuisance
Computer misuse
Conspiracy to murder
Conspiracy/preparation to commit felony
Conveying or possessing stolen property
Criminal trespass
Debts (civil)
Defamation
Default in rent payment (civil)
Defilement
Deliberate transmission of life threatening sexually transmitted disease
Drug possession
Drug trafficking
Embezzlement
Endengering human lives
Escape from lawful custody
Forgery/making false document
Fraud
Going armed in public
Human trafficking
Illegal entry (immigration)
Illicit brews
Impersonation
Incest
Incitement to violence
Indecent assault
Manslaughter
Murder
Neglect of duty
Negligent act causing death
Obtaining money or goods by false pretence
Operating without licence
Piracy
Possession/use/making of counterfeit money
Promotion of sectarianism
Prostitution or soliciting or aiding prostitution
Rape
Robbery
Robbery with violence
Sedition
Smuggling
Stealing/theft
Terrorism
Threatening to kill
Threatening to violence
Traffic offences
Treason
Unnatural offences
Wilful demage to property
Other offense
Offending history
No
Yes
Office Site:-
Birmingham
Leeds
London
Manchester
Newcastle
OK to contact by mobile
Yes
No
OK to contact by phone
Yes
No
OK to leave message?
Yes
No
OK to phone?
Yes
No
OK to write?
Yes
No
On a scale of 0 - 10 please score your personal confidence of how best to support others with a mental health problem before the course
6
1
2
3
4
5
0
7
8
9
10
Onboarding Status
Inactive
Trained
Live
Alumni
One Big Thing (What they are here to receive from Open Door)
Asylum Seeker
Befriending
CAP 1-to-1
Clothing
Community Connection
Foodbank
Housing issues
RESET
SIM card
Make The Call
Reading Made Easy
Shower
Opening comments checklist
Check volunteer personal details are correct on application form
Explain that data will remain confidential and stored both by LifeCare Edinburgh Limited and Space & Broomhouse Hub
Explain role of volunteer, outline training and support offered to volunteers
Other (Please specify) - I.Joining/off-signing operations for our seafarers
Other (Please specify) - LOGISTICS
Other (Please specify) - n/a
Other (Please specify) - NA
Other (Please specify) - None
Other (Please specify) - operations - passenger
Other (Please specify) - Operations - Provisions and Bond (Seachef)
Other (Please specify) - OPERATIONS- DRY
Other (Please specify) - Operations of marine supply
Other (Please specify) - Operations Support
Other (Please specify) - Port Operations
Other (Please specify) - prefer not to get in detail
Other (Please specify) - Procurement
Other (Please specify) - project service
Other (Please specify) - Recruitment
Other (Please specify) - Reservation and ticketing
Other (Please specify) - SCM - Coordinator
Other (Please specify) - Seachef- Provision & Bond
Other (Please specify) - Ship supply
Other (Please specify) - Supply provisions
Other (Please specify) - ICKETING
Other (Please specify) - Training
Other (Please specify) - travel
Other (Please specify) - travel / education
Other (Please specify) - TRAVEL BOOKINGS
Other (Please specify) - travel consultant
Other (Please specify) - travels
Other (Please specify) - treasury/ invoices with PO
Other (Please specify) - Vessel Owning Operations
Other (Please specify) - VESSELS PERFROMANCE
Other (Please specify) - VISA
Post Fixtures
Opportunity for funding (Do you think there is an immediate or longer term opportunity for funding)
Yes
No
Option
Enquiry
Engaged
Options
Verbal
Paper
Options
Verbal
Paper
Organisation Category
Agency
Arts and Culture
Church
Community Sustainability Group
Consultant
Education
Energy
Environmental Charity
Farming
Food/Hospitality
Funding body
Housing
Individual
Local Authority
Local Authority Councillor
National Park
NHS
Other business
Other Charity
Other Community Group
Other Land Use
Social Housing
Social research
Sport
Strategic Oversight Board
Tourism
Town or parish council
Transport
Utilities
Voluntary
Waste
Youth
Organisation Name
Eastside Community Trust
Ambition Lawrence Weston
Bristol Green Capital Partnership
Centre for Sustainable Energy
Bristol City Council
Bristol Disability Equality Forum
ACH
Heart of BS13
Lockleaze Neighbourhood Trust
Organisation Type
Community sector - Community groups/organisations
Other third sector - Social housing, NGOs
Public sector - Local authorities and other public sector
Business - Private sector businesses
Other ethnic group
Arab
Other
Other Forms of Reach
PR
Cold Outreach
People Reached via Partners
Paid Display Ads
Paid Social Ads
Paid AdWords
Client Widget Impressions
People Reached Via Event
Other Sources of Unique Website Visits
Search Engine
Direct URL
Referral
Other types of health professionals involved in your treatment
Counsellor
Psychologist
Community Psychiatric Nurse
Social Worker
Mental Health Practitioner
Outcome
Successful
Unsuccessful
Overall, on a scale of 1 - 10 where one is not satisfied at all and 10 is completely satisfied, how satisfied are you with your life nowadays?
1 (Not Satisfied)
2
3
4
5
6
7
8
9
10 (Completely Satisfied)
Oversight Area
A02
A06
B03
B05
C03
C04
C05
C06
D05
D07
E02
E03
E06
E10
E11
F01
F02
F03
F05
F07
P45
I attached a copy of the P45 from my previous employer
I have not yet received a copy of my P45
Pa grŵp ethnig ydych chi'n teimlo sy'n eich disgrifio chi orau? (Dim ond un y gallwch ei ddewis)
Gwyn
Du
Du Prydeinig
Cymysg
Lluosog
Asiaidd
Prydeinig
Roma
Teithiwr
Grwp ethnig arall
Mae'n well gen I beidio á dweud
Participant Declaration
Yes - I agree
No - I disagree
Participant Sex
Female
Male
Prefer not to say
Partner
Project Management (WP1)
City Movement Building (WP2)
Community Hubs (WP3)
Sector & Campaigns Support (WP4)
Learning & Evaluation (WP5)
Partner: Cold/Warm/Hot
Cold - no contact previously
Warm - previous/current contact but no work carried out or previous work but no contact recently
Hot - working with currently/ have previously worked with and still in contact
Partner focus: EET or NEET
EET
NEET
Partners
Cardinal Wolme Memorial School for Kensington & Chelsea
The Big House
New Horizons Youth Centre Camden
New River College Islington
Emmanuel School
Partner sector
Admin/Clerical Work
Animal Welfare
Beauty
Care
Construction
Creative and Media
Education Sector
Emergency/Uniformed Services
Environment/Land
Finance
Hospitality
IT
Mechanic/Manufacturing
Mixed/Various
NHS/Medical
Other
Retail
Security
Sport
Transport
Further Education
Partnership Level
Main delivery partner (1 of the 5)
Element partner
Patient ethinicity
English
French
German
Indian
Patient Ethnicity
England
France
Spain
Italy
Germany
Patient Ethnicity
India
Europe
Ireland
Brazil
North Korea
Patients
Name
Date of Birth
Address
Patient’s Ethnicity
How many dependents do they have
Why this person needs our help
Attach their signed consent
Next of Kin
Next of Kin name
Next of Kin phone
Next of Kin email
Next of Kin address
Patients
Date of Birth
Address
Patient’s Ethnicity
How many dependents do they have
Why this person needs our help
Name
Patients
Name
Date of Birth
Address
Patient’s Ethnicity
How many dependents do they have
Why this person needs our help
Patients
English
English
English
English
Patients 2
English
English
English
English
Patient's Enthnicity
English
French
German
Indian
Italian
Patient's Ethicity
English
French
German
Indian
Italian
Patient's ethinicity
English
frecnch
German
Indian
Patient's Ethinicity
India
Australia
USA
France
Germany
patient's ethnicity
Empty Answer Choice
Empty Answer Choice
Empty Answer Choice
Empty Answer Choice
Patient's ethnicity
Italian
Indian
French
Spanish
American
Patient’s Ethnicity
Indian
English
German
French
Italian
Native American
Patient’s Ethnicity
india
USA
UAE
Germany
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
English
Indian
French
German
Patient’s Ethnicity
English
Telugu
Tamil
Kannada
Patient’s Ethnicity
England
France
Germany
America
India
Patient’s Ethnicity
French
German
Canadian
Europian
Patient’s Ethnicity
India
USA
UK
Spain
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
Englsih
French
German
Indian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
India
Brazil
China
Bangladesh
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
Freanch
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
India
Russia
America
Brazil
UK
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
French
Dutch
German
Mandarin
Patient's Ethnicity
India
UK
Germany
Russia
USA
Patient's Ethnicity
USA
Germany
India
Italy
France
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
English
Telugu
Hindi
Patient's Ethnicity
English
French
German
Indian
Italian
Patient's Ethnicity
India
America
France
China
Germany
Patient's Ethnicity
English
Spanish
German
Serbian
Nigerian
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
India
Pakistan
Srilanka
Nepal
Canada
Patient’s Ethnicity
English
French
German
indian
Italian
Patient’s Ethnicity
India
Russia
USA
china
Japan
Patient’s Ethnicity
White
Black
Asian
Prefer not to say
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
English
French
German
Italian
Patient’s Ethnicity
India
Spain
Russia
Germany
UK
Patient’s Ethnicity
english
french
indian
german
italian
Patient’s Ethnicity
Tamil
English
Malayalam
French
Patient’s Ethnicity
sri Lanka
india
china
bhutan
russia
Patient’s Ethnicity
India
Italy
United Kingdom
United Arab Emirates
Turkey
Patient’s Ethnicity
sri Lanka
india
bangladesh
china
russia
Patient’s Ethnicity
English
French
German
indian
Italian
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
India
United States
United Kingdom
United Arab Emirates
France
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
English
French
German
India
Italian
Patient’s Ethnicity
White
Black
Asian
Prefer not to say
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
India
China
Russsia
USA
Patient’s Ethnicity
English
French
German
Indian
Italian
Patient’s Ethnicity
English
French
German
Indian
Italian
Patients Ethnicity
United Kingdom
India
USA
Australia
China
PATIENT'S ETHNICITY
ENGLISH
FRENCH
GERMAN
HINDI
Paying Member
Yes
No
Payment method
Invoice
Paypal
Permission granted to store data relating to their child if U18
Yes
No
Permission to contact
Yes
No
Permission to contact GP?
Yes
No
Permission to contact health visitor?
Yes
No
Permission to contact other agencies?
Yes
No
Permission to contact police contact?
Yes
No
Permission to contact school contact?
Yes
No
Permission to contact social care contact?
Yes
No
Permission to contact voluntary organisation?
Yes
No
Permission to send them surveys
TRUE
FALSE
Permission to store for marketing
Yes
No
Permission to store photos and digital recordings?
Yes
No
Permission to store their contacts
Yes
No
Person Type
Child
Parent/Guardian
Adult
Other
Person Type
Child
Parent/Guardian
Adult
Other
Phone number
English
French
German
Indian
Phone number
Empty Answer Choice
Empty Answer Choice
Empty Answer Choice
Empty Answer Choice
Photo consent to share images
Yes -2024
No -2024
Physical/sporting ability
High
Above
Average
Below
Low
Place 2 Be consent:
Yes
No
Please also confirm if you are not listed on the either of the following
I confirm that I am not listed on the Adult's Barred List/ I confirm that I am not listed on the Children's Barred List
Please confirm that you are available to attend the face-to-face session on 22nd and 23rd August.
Yes, I can attend
No, I can't attend
Please confirm which methods of communication the person being referred has agreed that we can use to contact them (tick all that apply).
Phone
Letter
Email
Text
Voicemail
Please confirm which methods of communication the person being referred has agreed that we can use to contact them (tick all that apply).
Telephone
Letter
Email
Text
Voicemail
Please confirm you consent for us to:
Contact you regarding The AMANI Project
Require a negative COVID test on arrival (If successful)
Record you at the Insight Day (If successful)
Add you to our AVIARD Update & Newsletter
Please detail which of our PRAMS services you would like to access below - please read eligibility criteria on our service schedule via our website first https://tinyurl.com/mu54zf5z)
PRAMS You & Your Baby
PRAMS You & Your Bump
PRAMS You & Your Toddler
PRAMS Support Group
PRAMS Talking Therapies (One-to-One)
Please detail which of our PRAMS services you would like to access below: please read eligibility criteria on our service schedule via our website first (https://tinyurl.com/mu54zf5z)
PRAMS You & Your Baby
PRAMS You & Your Bump
PRAMS You & Your Toddler (Wrexham only)
PRAMS Support Group
PRAMS Talking Therapies (One-to-one)
Please detail which service you would like to access below - please read eligibility criteria on our service schedule via our website first (https://t.co/2zmHrbtUnR)
BYW 1-2-1 (Lifestyle Coaching)
PRAMS (Groups aimed at parents and expectant parents)
Group sessions (such as 'Five To Thrive')
Self-Advocacy
Courses (such as 'Mental Health Awareness')
Weekly Support Group (for Flintshire parents)
Please detail which service you would like to access below:- please read eligibility criteria on our service schedule via our website first (https://t.co/2zmHrbtUnR)
BYW 1-2-1 (Lifestyle Coaching)
BYW Walk in Bellevue Park
BYW Arts and Crafts
BYW Allotment Group ('A Place to Grow')
BYW Board Games (winter months only)
PRAMS You and Your Baby
PRAMS Support group
PRAMS You and Your Bump
Group session (such as 'Five To Thrive')
Please indicate all methods you are happy for us to use to contact you
Phone
Text
Voicemail
Letter
Email
Please indicate which workshops you would like to book on to
1. Understanding your feelings - 17th Feb
2. Doing things that make you feel better - 24th Feb
3. Looking at things differently - 3rd March
4. Building inner confidence - 10th March
5. How to fix almost anything - 17th March
6. The things you do that help – and the things you do that don’t - 24th March
7. Keeping your cool - 31st March
8. 10 things you can do to feel happier straight away - 7th April
Please indicate your marital status
Cohabiting
Divorced/Dissolved Civil Partnership
Married/civil partnership
Separated
Single Widowed
Prefer not to say
Other (please specify)
Please indicate your religion
Buddhist
Catholic
Hindu
Jewish
Muslim
Protestant
Sikh
Prefer not to say
None
Other (please specify)
Please list whether you have the following policies in place
Employment Contracts
Disciplinary
Grievance and Appeal Procedures
Mediation
Capability Policy
Complaints procedure
Whistleblowing Policy
Equal Opportunities Policy
Health & Safety
Protection of Children and Adults who are Vulnerable
Lone Working
Working Time Regulations
Maternity Leave
Paternity Leave
Adoption Leave
Parental Leave
Right to time off for emergencies
Right to join a Trade Union
Smoking Policies
Age Discrimination
Volunteering: Recruiting
Volunteering: Volunteer Agreement
Volunteering: Training
Volunteering: Expenses
Volunteering: Performance issues
Health & Safety: Office Health and Safety
Health & Safety: Display Screen Equipment guidelines
Health & Safety: Manual Handling
Health & Safety: Risk Assessment
Please select the following that apply to the person being referred to Vintage Vibes:
I am able to independently access my own garden and/or go out for a walk without assistance
I would be happy to have a telephone call from a volunteer
I would only be able to have an indoor home visit from a volunteer
Please select the highest level of education you completed
I received no formal education
Primary school
Secondary school
College/University
Other
Please select the highest level of education you completed (Ghana)
No Formal Education
Primary School
Junior High School
Senior High School
College/University
Please select which out of the below you would like to register for:
A Parent's Guide to: Managing Stress and Anxiety - 6 week course
A Parent's Guide to: Unwinding Your Mind
Please select 'Yes' to indicate if you agree for your child's photograph to be taken. We will request specific permission if we wish to use the photo for any purpose other than to give you feedback.
Yes
No
Please sign here if you are happy for me to share this information with your tutor.
Yes
Please sign me up to Sport 4 Life UK's newsletter
Yes
No
Please specify your ethnicity?
Black / Black / British / African / Caribbean / any other Black British / African / Carribean background
Mixed / Multiple ethnic groups
Please tick one of the following three statements:
This is my first job since the start of the tax year
I have had another job since the start of the tax year but this is now my only job
I currently have another job or pension
Please tick to indicate if you agree for your child's photograph to be taken. We will request specific permission if we wish to use the photo for any purpose other than to give you feedback.
Yes
No
Not Web
Please tick which track you are applying for
Endorsed Track £195.00
ATHE Track £360.00
Police/YOT
None
Historic
Current
Positive attitude to volunteering/work
1
2
3
4
5
Potential Community Adventurer?
Yes
No
Preferred contact by
Email
Post
Phone
What'sapp/ Messenger
Preferred Contact Person for setting up Vintage Vibes
Please contact the potential VIP (person being referred) about setting up Vintage Vibes
Please contact the Next of Kin/Emergency Contact person about setting up Vintage Vibes
Please contact the Referrer about setting up Vintage Vibes
Preferred day of visit/telephone call (Please select all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Preferred method of contact
Phone
Text
Email
Preferred method of contact
RV email
Personal email
Mobile
Whatsapp
Text
Preferred method of service delivery
Face to face
Zoom
Telephone
Facebook Groups
Preferred room size
LARGE SIZE
MEDIUM SIZE
SMALL SIZE
Preferred time slot of visit/telephone call (Please select all that apply)
Morning
Afternoon
Early Evening
Preferred title
Mr
Mrs
Ms
Miss
Mx
Previous CP/CIN plan
Yes
No
Previous institution
School
FE College
6th Form College
Overseas
Primary or Secondary contact within organisation
Primary
Secondary
Printer available
Yes
No
Prison - Kenya
Kamiti Maximum
Kiambu Main
Lang'ata Women
Machakos Main
Machakos Women
Naivasha Maximum
Naivasha Medium
Naivasha Women
Thika Main
Thika Women
Prison Security Level
Low Security
Medium Security
Maximum Security
Prison Security Level
Low Security
Medium Security
Maximum Security
Prison (Training)
Kamiti Maximum
Machakos Main
Naivasha Maximum
Thika Main
Thika Women
Privacy Information Issued?
Yes
No
Profile Role
CYP Partner
External Partner
family/household
parent/carer partner
RCH partner,
Empty Answer Choice
Empty Answer Choice
Programme
10 Week Nurturing Programme
Working 1:1
Welcome to the World
Parenting Puzzle Workshops
Playful Parenting
Teen Programmes
Hertfordshire Teens
Conflict
Education Training
Workplace
Other
Accred
HAPPY
Islamic
Webinars
Progress
Initial Contact
In Process
Complete
Progress through Phase 1
Partnership Agreement Signed
Milestones Agreed
Attended Retreat
CEO Meeting Held
Evidence Submitted
Deadline Met
Project Lab Theme:
Employability
Education and Training
Other
Project's Status
Not approved
Approved but not started
Funded
On-track 5 yr
Future projects 5-10 yr
Project Status
In Development
Ready to Publish
Ongoing
Finished
Projects that staff work on :
Admin (The Rendezvous)
Advice & Information
Agencies
Anxious 2 Awesome
Bekah's Kitchen Table
Employability waiting list
Fundraising
General Contracts
Learning Sherborne
Learning waiting list
Learning Yeovil
Mental Health & Wellbeing by Staff
Mental Health & Wellbeing by Volunteer 1
Mental Health & Wellbeing by Volunteer 2
Mental Health & Wellbeing by Volunteer 3
Mental Health & Wellbeing by Volunteer 4
Mental Health & Wellbeing by Volunteer 5
Mental Health & Wellbeing by Volunteer 6
Mental Health & Wellbeing by Volunteer 7
Mental Health & Wellbeing by Volunteer 8
Mental Health & Wellbeing waiting list
Safeguarding
Special Projects (The Rendezvous)
Staff (Management)
The Future Is Yours
The Good The Bad The Ugly
Trustees
Volunteers
Young Parents Gillingham
Young Parents Sherborne
Young Parents waiting list
Punctuality
1
2
3
4
5
Pupil Premium
Y
N
Pupil Premium:
Yes
No
Pupil Premium:
Yes
No
Pupil Premium*
Yes
No
Pupil's SIMD
1
2
3
4
5
6
7
8
9
10
Pupil's Year Group
Reception
Year 1
Year 6
Year 7
Year 8
Year 9
Year 10
Year 11
Year 12
Year 13
NEET
Year 2
Year 3
Year 4
Year 5
Q10. HOW DO YOU DETERMINE WHETHER THE ACTIONS YOU'RE TAKING TO FACILITATE YOUR ORGANIZATION'S GROWTH ARE YIELDING POSITIVE RESULTS?
Do Not Know
Metrics
Feedback
Retention (Staff or Customers)
Impact Report
Donations
Q11. WHO DO YOU HOPE TO HELP OR SERVE WITH YOUR ORGANIZATION?
Do Not Know
Youth & Children
Boys & Men
Girls & Women
Business Owners/Entrepeneurs
Elderly
Immigrants & Refugees
Physical & Mental Disabled persons
Students
Recent Graduates & Professionals
LGBTQIA2S+
Parents, Mothers & Fathers
Artists
Black & Indigenous
Q12. HOW ARE YOU CURRENTLY CONNECTING WITH THOSE YOU HELP?
Do Not Know
Online Newsletter
Email
In Person
Outreach
Q13. WHAT MEASURES HAVE BEEN IMPLEMENTED TO ENSURE THE SMOOTH AND EFFICIENT FUNCTIONING OF YOUR ORGANIZATION'S OPERATIONS?
Do Not Know/NONE
Delegation
Assigning Tasks or Empowering others
Standard Operating Procedures
Monitoring
Effective Communication
Accountability
Audits
Q14. ARE THERE ANY PARTICULAR GOALS OR TARGETS YOU AIM TO ACCOMPLISH IN THE FUTURE TO SUPPORT THE GROWTH AND DEVELOPMENT OF YOUR ORGANIZATION?
Do Not Know
National or Global Expansion
Strategic Partnerships
Diversify Funding
Increase Impact
Brand Recognition
Q15. DO YOU CURRENTLY HAVE A BOARD OF DIRECTORS?
Yes
No
Q16. ARE ANY OF THE BOARD OF DIRECTORS ACTIVELY INVOLVED IN THE OPERATIONS?
Yes
No
Q2 Are you a member of SBC?
Yes
No
Q3 Which SBC Membership are you on?
Get listed- Free
Get listed- Get Featured $149 CAD/year
Get listed- Get Featured, Get Promoted $249 CAD/year
Q4 What is your Organization's Status?
Government Registered NonProfit- able to provide tax receipts in your country
Government Registered NonProfit- unable to provide tax receipts in your country
Unregistered Organization(Community based Grassroots etc)
Other
Q5. How would you characterize your organization?
Startup
Established
Expanding
Struggling
Merging
Dissolving
Other
Q6. WHAT DO YOU NEED HELP WITH?
Governance (Onboarding, By-Law, Board Management)
Operations (Standard Operating Procedures)
Website Development and Optimization
Program Development
Financials (Budget, Reporting, Accounting, Bookkeeping, Income Taxes)
Peer Support services: community, CMHT and PCN Peer Support
Positive Minds
Remind Dementia Support
Solent Recovery College
Talking therapies: iTalk
Togetherall
Wellbeing Advisors and Peer workers within PCNs
Wellbeing Centres
Working Feedback
Youth Affinity
Setting
Community: large scale
Community: small scale
Schools
Workplace
Sex
Male
Female
Sex
Male
Female
Sex
Female
Male
Intersex
Asexual
Prefer not to say
Sex
Male
Sex
Female
Male
Sex
Male
Female
Sexuality
Lesbian
Gay
Bisexual
Heterosexual
Sexuality
To young to say
Straight
Gay
Lesbian
Bi
Other
Prefer not to say
Sexual Orientation?
Heterosexual
Bisexual
Gay Woman
Gay Man
Other
I prefer not to say
Sexual Orientation: My sexual orientation is towards someone:
Of the same sex (this covers gay men and lesbian)
A different sex (this covers heterosexual men and women)
Of the same sex and of the opposite sex (this covers bisexual men and women)
Prefer not to say
Sharing information consent - I agree to allow Advance Brighter Futures to store and process my personal data
Yes
No (If selected, we cannot accept onto our project/s)
Should a 2nd dose of medication be administered if the 1st dose is not effective
Yes
No
Should an ambulance be called at the same time as administering the 2nd dose
Yes
No
Should an ambulance be called at the same time as the 1st dose is given
Yes
No
Should the child/YP remain in their chair all the time
Yes
No
Should the feed be kept at room temperature or chilled
Room temperature
Chilled
Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination. In addition, I agree that this information will be retained in my personnel file during employment and for up to six years thereafter and understand that information will be processed in accordance with the General Data Protection Regulation (GDPR)
I agree
No
Signed data consent form
Yes
No
SIMD Number
1
2
3
4
5
6
7
8
9
10
Similar Background
Yes
No
Since this time last year, has your understanding of how to apply your faith to your sporting life changed at all?
Yes
No
Size (Annual Income)
Micro (under £50k)
Mini (£50k-£500k)
Small (£500k-£1M)
Medium £1M-10M)
Large Over £10M
Skill Levels Apprenticeship
The apprentice has been shown this skill
The apprentice has practiced this skill
The apprentice can do this with supervision
The apprentice can do this by herself
The apprentice can do this to a good standard
Skin Name
Nakamarra
Jakamarra
Nungarrayi
Jungarrayi
Nampijinpa
Jampijinpa
Napanangka
Japanangka
Nangala
Jangala
Napaljarri
Japaljarri
Napurrula
Jupurrula
Napangardi
Japangardi
Social Care involvement?
None
Historic
Current
Social Emotional Experiences
Maintaining Positive Relationships
Low confidence
Low resilience
Management of feelings
Aspirations
Mental Health concerns
Social Enterprise
Planning Meeting
Making Session
Selling Session
Items Made
Items Sold
Budgeting Session
New Ideas
New Skills Learnt
Socially Isolated
Yes
No
Social Media Reach - Content Impressions
Facebook
LinkedIn
Youtube
Twitter
Instagram
Pinterest
Social Media Sources of Unique Website Visits
Twitter
LinkedIn
Youtube
Github
Facebook
Social Network and Support (LL import)
Yes
No
Sources of Leads Generated
Website Forms
Email Introductions & Other Sources
Organisation Accounts Created on Makerble
New Hubspot Deals
Newsletter Signups
HotJar Recruits
Special Educational Needs & Disability (secondary)
No Special Educational Need
SEN Support
Education, Health and Care Plan
Specialism
MHWB
Education
Young parents
Advice and Information
Finance
Other
Specialisms within their sphere of equalities work
Children
Women
Refugees
Specific ethnic group
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Any other Asian background
Black/African/Caribbean/Black British: African
Black/African/Caribbean/Black British: Caribbean
Any other Black/African/Caribbean background
Mixed/Multiple ethnic groups: White and Black CaribbeanMixed/Multiple ethnic groups: White and Black Caribbean
Mixed/Multiple ethnic groups: White and Black African
TEEN PROGRAMMES Stress and the Brain in Children and Teenagers
TEEN PROGRAMMES Talking Teens
TEEN PROGRAMMES Talking Teens for Parent Group Leaders
TEEN PROGRAMMES Understanding Teenagers
WEBINARS Parent Webinars (all)
WELCOME TO THE WORLD Parent Group
WELCOME TO THE WORLD Welcome to the World Refresher Day
WELCOME TO THE WORLD Welcome to the World
WELCOME TO THE WORLD Welcome to the World for Parent Group Leaders
WORKING 1:1 Working 1:1 with Parents
WORKING 1:1 Working 1:1 with Parents of Teens
WORKING 1:1 Working with Families with Multiple Challenges
WORKING 1:1 Parenting, Culture & Religion
WORKPLACE 1 Day Emotional Health in the Workplace
WORKPLACE Parenting in the Workplace Webinar
WORKPLACE Emotional Health in the Workplace Workshop
WORKPLACE Half Day Emotional Health in the Workplace
WORKPLACE Parenting in the Workplace Workshop
PLAYFUL PARENTING Playful Parenting
HERTFORDSHIRE TEENS My Teen Brain
PLAYFUL PARENTING Parent Group
Subject of Phone Calls
FGM
Denying education
Denying freedom of movement
Honour-based violence
Sexual abuse
Emotional abuse
Physical abuse
Financial abuse
Control
Housing
Education
Subscribed to bulletin
Yes
No
Substance misuse
No
Yes
Suffix
Mr
Mrs
Miss
Other
Supervision required
1:1
1:2
1:3
1:4
1:5
1:6
2:1
Supportive of brokerage campaign
Yes
No
Support Networks
Family
Friends
Workers/School
Other
Swimming capability (My child can swim 25m without assistance)
Yes
No
Team
Option 1
Option 2
Team Client
Dulwich Prep London
The Iffley Academy
Z - Test client
Z - Test client 2
Teamwork - measures how well this individual gets along with fellow paralegals, respects their rights and shows a cooperative spirit
Outstanding
Exceeds expectations
Meets expectations
Below expectations
Unsatisfactory
Don't know
Technical/Fleet Operations Job type - please specify
Electrical Engineer
Fleet Manager
HSEQ Executive
HSEQ Superintendent
IT Analyst
Marine Superintendent
Other (Please specify) - Data Analyst
Other (Please specify) - IT / Maintenance System support
Other (Please specify) - Procurement/Logistics
Other: Dry Dock Superintendent
Port Operations Executive
Technical Advisory
Technical Assistant / Document Controller
Technical Assistant / Executive
Technical Manager
Technical Operations Manager
Technical Superintendent
Vetting Coordinator
Telephone Number
Mobile
Home
Work
Other
Term
Spring
Summer
Autumn
test 1234
a
b
c
d
test22
rr
rrs
Test33
1
Test AN dropdown
Option 1
Option 5
Option 6
Option 7
Option 8
Option 10
Test Category Field
1
2
3
4
test field 1
a
b
c
d
test field 2
a
b
c
d
testing 1
11
12
13
14
testing drop 1
English
French
German
Others
testing mail ratio set
1
2
3
4
test list
a
a
Empty Answer Choice
Empty Answer Choice
Test list
12
123
334
213
test mail ratio set
1
2
3
4
The following has been seen as evidence of right to live/work in the UK:
Full passport (EU member)
Full passport (non EU Member State) - Passport either endorsed indefinite leave to remain or includes work or residency permits or visa stamps (unexpired)
Identity Card issued by the Home Office in place of visa, confirming the individual's right to stay and work in UK
Letter from the UK Immigration and Nationality Directorate granting indefinite leave to remain (settled status)
Residency permits for foreign nationals (usually in a passport)
The information given in this form is correct and up-to-date and it is my responsibility to inform PLUS of any changes to this epilepsy care plan.
Yes
No
The LLWR Privacy Notice has been made available to you which explains how your data will be processed by the Welsh Government.
Yes
No
The meeting today met my expectations
Strongly Disagree
Moderately Disagree
Neither Agree/Disagree
Moderately Agree
Strongly Agree
Third language learnt
french
English
German
Spanish
Other
This person is a child (LL import)
Yes
No
This person is a Parent
Yes
No
Through which medium would you like to be taught?
English
Welsh
Billingually
Tick box if epilepsy update care plan has been completed
Yes
No
Tick here if signed by school rather then parent
Yes
No
Time slots
10AM - 11 AM
11AM - 12PM
12PM - 1PM
1PM- 2PM
2PM- 3PM
3PM- 4PM
Tîm y cyfeirwyr (Dim ond un y gallwch ei ddewis)
TIMC Uwchradd
TIMC cynradd
Therapïau Seicolegol
Coed Celyn
Heddfan
Triniaeth Gartref
Tîm Adsefydlu Cymunedol
Arall
Title
Mr
Mrs
Miss
Title
Mr
Mrs
Miss
Ms
Title
Mr
Miss
Mrs
Ms
Title
Mr.
Mrs.
Miss
Title:
Miss
Mr
Mrs
Ms
Topic chosen
Sustanibility
Water conservation
Plant potting
Waste reduction
Topics covered
Sustanibility
Water conservation
Plant potting
Waste reduction
Town
Aberfoyle
Airth
Alloa
Alva
Auchterarder
Avonbridge
Bainsford
Balfron
Bannockbourn
Blair Drummond
Blairingone
Blairlogie
Blanefield
Bo'ness
Bonnybridge
Braco
Braehead
Bridge of Allan
Brightons
Broomridge
Buchlyvie
Callander
Cambusbarron
Cambuskenneth
Camelon
Carron
Carronshore
Causewayhead
Clackmannan
Coalsnaughton
Cornton
Cowie
Crianlarich
Deanston
Denny
Dollar
Doune
Drymen
Dunblane
Falkirk
Fallin
Fintry
Gargunnock
Gartmore
Grangemouth
Haggs
Hallglen
Highland Gate
Killearn
Killin
Kincardine
Kings Park
Kippen
Kippen Station
Larbert
Lionthorn
Lochearnhead
Maddiston
Menstrie
Near Gartmore
New Carron
Plean
Polmont
Port of Menteith
Raploch
Redcar
Redding
Reddingmuirhead
Riverside
Rumford
Sauchenford
Sauchie
Shieldhill
Sheriffmuir
Slamannan
St Ninians
Stenhousemuir
Stirling
Strathblane
Strathyre
Thornhill
Throsk
Tillicoultry
Top of the town
Torbrex
Tullibody
West Plean
Westquarter
Whins of Milton
Trainer/ Advisor to beneficiary ratio
1:1
1:2-1:5
1:6-1:10
1:11-1:15
1:16--1:20
1:20+
Training
Yes
No
Training approach
Direct/ vulnerable area
Cascade
Training approach
Direct/ vulnerable area
Cascade
Training approach
Direct/ vulnerable area
Cascade
Training approach
Direct/ vulnerable area
Cascade
Training Topic
Child Protection
Safeguarding
Domestic Violence
Mental Health Awareness
Transport - booster seat needed
Yes
No
Transport home from the event
Yes
No
Transport to the event
Yes
No
Trial Court
Gatundu
Kadara
Kandara
Kigumo
Kithimani
Riuru
Thika
Thika/Kiambu
Ttitle
Mrs
Mr
Miss
Type
Prisoner
Prison Staff
Other
Type of Agency (Individuals)
GP
Counsellor
Psychologist
Community Psychiatric Nurse
Social Worker
Mental Health Practitioner
Type of Animals 1
Elephants
Lions
Tigers
Type of Business
Pub
Cafe
Food outlet
Other business
Type of Community
Demographic
Geographic
Type of impairment?
Physical Impairment
Sensory Impairment
Long Standing Illness or Health Condition
Mental Health Condition
Learning Disabilities
Other
I prefer not to say
Type Of Intervention
Calls home
Parents in
Teacher conference
Tutor-ST meeting
Cause for Concern
Disciplinary Stage 1
Disciplinary Stage 2
Disciplinary Stage 3
Disciplinary Stage 4
Daily Report
Weekly check-in
SLT meeting
Type of Meeting
The European Union
The United Nations
The African Union
Type of membership
General network member
Steering group
Formal member
Type of New Customer
Paying
Free Trial
Type of organisation
Education (primary, secondary, FE or HE)
Housing Association
Local Authority
Public Health
Registered Charity
Type of organisation
Think tank
Third sector
User led
Type of organisation
School
University
Community organisation
Orphanage
Business
Type of Organisation
Charity
CIC
College
Company
Foundation
Government/Council
JCP
Network member
Other
Police
Probation services
School
Training Provider
University
Youth Group
Type of Organisation
Umbrella
Consultant
Type of Organisation
School
Community Organisation
Type of Partner
Certified Set Up Partner
Referral Partner
Type of person
Professional who works with families/young people
Young person or member of a family who has received a grant from Buttle UK
Type of Referral Partner
Housing
Addiction
Community Groups
Mental Health
Social Services
Health Centres
Churches
Politicians
Advice Centres
Universities
Probation Boards
Type of role
C-suite
Director
Head of
Manager
Coordinator
Officer
Intern
Volunteer
Trustee
Type of School
Primary
Secondary
Type of Sentence
Remand / not yet sentenced
Death sentence
Life imprisonment
Under six months
Six months to a year
Presidential pleasure
Unavailable
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Type of Sentence
Life
Death
Fixed Amount of Time
Type of Service/Activity Signposted To
Day Centre
Community Group - Interest led
Community Group - Wellbeing
Practical Support
Other
Type of Session/ Funder
Sutton Life Centre
On The Street
After School Club
AYCES
Doorstep Sports Club
Worcester Park
Detached (Other)
Other
Type of support required
Food
Essentials
Fuel
Type of team member
Staff member
Student Volunteer
Parent Volunteer
Volunteer
Trustee
Type of work
Advocacy
Campaigning & Lobbying
Case Management, Programme Delivery and Service Delivery
Research
Types of activity
Advice
Advocacy
Campaigning
Lobbying
Types of Adult Social Services involved in
VC to add
VC to add another
Types of Child Social Services involved with?
VC to add
VC to add another one
Types of involvement with Social Services
Adult
Children
Types of past/present involvement with the criminal justice system
PSNI investigations
Probation
Prison
Public Prosecution Service
Court
MARAC
Non-Molestation Order
VISOR
Other
Underrepresented individual
No
Yes
Unemployed
Yes
No
Unemployment duration
0-3 months
4-6 months
7-9 months
10-12 months
1-2 years
2+ years
Never been employed
University
University of British Columbia
Canada
Unsuitable referral?
Yes
No
Upskilling
Yes
No
Verdict score for CORE forms
Not at all
Only occasionally
Sometimes
Often
Most or all of the times
Video consent
Only for videos which DON'T identify them
Yes, for videos which do include their face or identifying features
Yes, to be used on their website, social media and other digital communications
Empty Answer Choice
VIP Circumstances
Dementia
Hearing impairment
Housebound
Poor mobility
Stroke
Visual impairment
Volunteer area role
Admin
Trustee
Fundraising
TFIY
Tutor- English
Tutor- Math
Young Parents as per tutoring
Volunteering
Office Shift
Planning Meeting
One to One
Cooking
Training
Community Event
New Skill Learnt
Vulnerable Group
Asylum seekers
Children in care
Young carers
High levels of violence or sexual assault
Way of managing wellbeing
Avoidance
Alcohol/Drugs/Smoking
Aggression
Eating Disorder
Creative practices (art, drama, etc)
Self-Harming Behaviour
Talking to friends/family
Obsessive Thoughts/Behaviours
Runaway
Anti-Social Behaviour
Other
Weekly Activity
New Partners Recruited
ECF Messages Responded to
New Influencers Recruited
Potential Partners Contacted
Events Attended
Events Hosted
Speaking Opportunities Secured
Future Partnership Events Confirmed
Blog Articles Written
New Referral Sites Listed On
New/Updated Pages or Articles
Pieces of Press Coverage
Special Cause Weeks/Days Engaged In
Reviews Published
Networks Joined
Newsletters Sent
Well-Being (LL import)
Yes
No
Wellbeing Scotland Service Offered:
1:1
Group
Were you born in the UK?
Yes
No
We will have more projects and paid opportunities for young people in the future. Please let us know if you would be happy for us to contact you about these.
Yes, I am happy to be contacted about other projects
No, I do not want to be contacted about other projects
What age category do you fit into?
18-29
30-49
50+
What are you most interested in?
Mentoring
Sports sessions
Qualifications
Employability
Social Action
What best describes your job type?
Commercial
Finance/HR/Admin / Support
IT
Legal / Insurance
Middle Office
Operations (commercial / voyage)
Operations (commercial/voyage)
Other (Please specify)
Other (Please specify) - .
Other (Please specify) - Account Assistant
Other (Please specify) - Accountant
Other (Please specify) - Accounting
Other (Please specify) - Accounting Dept
Other (Please specify) - Accounts
Other (Please specify) - ACCOUNTS MANAGER CORPORATE AND COMPLIANCE
Other (Please specify) - admin support
Other (Please specify) - Administrative Assistant
Other (Please specify) - Advisor
Other (Please specify) - assistant
Other (Please specify) - Assistant to Management
Other (Please specify) - ASSIT. DATA OFFICER
Other (Please specify) - ASST DATA OFFICER
Other (Please specify) - Assurance Specialist
Other (Please specify) - Audit
Other (Please specify) - Back Office support
Other (Please specify) - Bunkers
Other (Please specify) - Business
Other (Please specify) - Business Developement
Other (Please specify) - Business Development
Other (Please specify) - Business Process
Other (Please specify) - Business Travel Consultant
Other (Please specify) - Bussiness Dev
Other (Please specify) - Buyer
Other (Please specify) - CAD Engineer
Other (Please specify) - Cadet Planning and operation
Other (Please specify) - Cadet training - Personnel Manager
Other (Please specify) - Catering Superintendent
Other (Please specify) - CENTRAL PMS TEAM
Other (Please specify) - Charterer
Other (Please specify) - Chef at MTC
Other (Please specify) - Communications
Other (Please specify) - COMPLIANCE
Other (Please specify) - Consultant
Other (Please specify) - Coordinator
Other (Please specify) - corporate services
Other (Please specify) - Crew Management
Other (Please specify) - Crew Service Centre (Myanmar)
Other (Please specify) - Crewing
Other (Please specify) - Crewing & documentations
Other (Please specify) - Crewing & Man management
Other (Please specify) - Crewing / Personnel
Other (Please specify) - crewing dept
Other (Please specify) - crewing operation
Other (Please specify) - Customer Account Officer
Other (Please specify) - Customer Relations
Other (Please specify) - Data Analyst
Other (Please specify) - Data Officer
Other (Please specify) - Documentation Analyst
Other (Please specify) - Education
Other (Please specify) - Education
Other (Please specify) - Engineering
Other (Please specify) - EQUIPMENT CONTROLLER
Other (Please specify) - Equipment Controller (Operations)
Other (Please specify) - Fire Fighting Instructor
Other (Please specify) - Fire Instructor
Other (Please specify) - Flag state personal team
Other (Please specify) - Flag State (Sr. Personnel Officer)
Other (Please specify) - Fleet personal Director
Other (Please specify) - Fleet Personnel
Other (Please specify) - Fleet Personnel Dept
Other (Please specify) - Fleet Personnel Manager
Other (Please specify) - FLEET PERSONNEL OFFICER
Other (Please specify) - Fleet Personnel Manager
Other (Please specify) - FLEET PERSONNEL OFFICER
Other (Please specify) - Fleet Pesonnel Manager
Other (Please specify) - Fleet Safety Specialist
Other (Please specify) - Health and Safety
Other (Please specify) - HR Marine
Other (Please specify) - HR MARINE SHORE
Other (Please specify) - HR MARINE SHORE BASED
Other (Please specify) - HSEQ
Other (Please specify) - HSSE
Other (Please specify) - Innovation
Other (Please specify) - Innovation and Improvement
Other (Please specify) - instructor
Other (Please specify) - Internal Auditor
Other (Please specify) - Key Account Manager
Other (Please specify) - KEY ACCOUNTS
Other (Please specify) - Lifting equipment
Other (Please specify) - logistics
Other (Please specify) - Loss prevention
Other (Please specify) - Loss Prevention Safety and Quality
Other (Please specify) - Maintenance
Other (Please specify) - maintenance team
Other (Please specify) - Management
Other (Please specify) - Manager
Other (Please specify) - Manager crewing
Other (Please specify) - MANNING
Other (Please specify) - Marine Operations
Other (Please specify) - Marine Quality Assurance
Other (Please specify) - MARITIME NAUTICAL FACULTY
Other (Please specify) - Marketing
Other (Please specify) - Marketing and Data
Other (Please specify) - Master Mariner
Other (Please specify) - Middle Management
Other (Please specify) - MQA
Other (Please specify) - OFFICE JOB
Other (Please specify) - Onboard Training Superintendent
Other (Please specify) - OPERATION
Other (Please specify) - Operation support/port operation
Other (Please specify) - Operational.
Other (Please specify) - Operations
Other (Please specify) - OPERATIONS (MANNING)
Other (Please specify) - Operations Admin Support
Other (Please specify) - Operations Admin Support
Other (Please specify) - OPERATIONS MANNING
Other (Please specify) - Operations/Admin Support
Other
Other (Please specify) - personnel
Other (Please specify) - Personnell
Other (Please specify) - PORT CAPTAIN
Other (Please specify) - Prefer not to say
Other (Please specify) - procument
Other (Please specify) - Procurement
Other (Please specify) - Procurement / Sourcing
Other (Please specify) - Psychologist
Other (Please specify) - Purchasing
Other (Please specify) - PURCHASING/ PROCUREMENT
Other (Please specify) - QHSE
Other (Please specify) - Quality
Other (Please specify) - Quality and Safety
Other (Please specify) - Quality Assurance
Other (Please specify) - Receptionist
Other (Please specify) - Recruitment
Other (Please specify) - Research and Commercial Plan
Other (Please specify) - Safety & Quality
Other (Please specify) - Safety and Quality, compliance
Other (Please specify) - Safety Instructor
Other (Please specify) - Senior manager operations support
Other (Please specify) - SENIOR TRAVEL CONSULTANT
Other (Please specify) - Sr. Chartering Manager
Other (Please specify) - Student
Other (Please specify) - SUPERVISOR
Other (Please specify) - Supplier Relations
Other (Please specify) - Supply Chain
Other (Please specify) - Supply Chain Officer
Other (Please specify) - Technical
Other (Please specify) - technical department lifting gear
Other (Please specify) - Technical support shore side
Other (Please specify) - Technical Trainer
Other (Please specify) - Technology
Other (Please specify) - Technology Support
Other (Please specify) - Trainee
Other (Please specify) - Trainer
Other (Please specify) - Training
Other (Please specify) - Training and Technical
Other (Please specify) - Training Officer
Other (Please specify) - Training/Logistics
Other (Please specify) - Travel
Other (Please specify) - TRAVEL CONSULATE
Other (Please specify) - Travel consultant
Other (Please specify) - TRAVEL DEST OPERATION
Other (Please specify) - Travel Management
Other (Please specify) - Travel technology
Other (Please specify) - Underwater Assistant
Other (Please specify) - Vessel Accountant
Other (Please specify) - Vessel Accounts
Other (Please specify) - Vetting
Other (Please specify) - warehouse & quality
Other (Please specify) - warehouse keeper
Other (Please specify) - Warehouse Operatives
Other (Please specify) - warehouse supervisor
Senior management
Technical / Fleet / Port Operations
Technical / Fleet Operations
What days are you available to volunteer?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What ethnic group do you feel best describes you?
White
Black/Black British
Mixed/Multiple
Asian/British
Roma/Traveller
Other Ethnic Group
Prefer not to say
What ethnic sub group do you feel best describes you?
White Welsh
White British
White Irish
White - Other
African
Caribbean
Black/Black British - Other
White & African
White & Black
White & Asian
Indian
Pakistani
Bangladeshi
Chinese
Asian/British - Other
Roma
Irish Traveller
Other traveller
What functional skills qualifications are you interested in?
Maths - Level 1
Maths - Level 2
English - Level 1
English - Level 2
Unsure
What gender do you identify as?
Female
Male
Prefer not to say
What is available
CAP
Benefits Advice
Befriending
Link Referrals
What is the child's current SEN status?
No SEN
SEN suspected
SEN support provided (i.e school is providing some support)
Currently going through an EHCP needs assessment
Has an EHCP
What is the child's social care status?
None
Section 20
CP
LAC
Section 31
CIN
What is the client seeking?
Appeal
Bail
Other
What is the highest level of qualifications you have achieved?
Bachelor's Degree
College Qualifications
Doctorate Degree
Less than senior / high school qualification
Master's degree
Other
Professional qualification / degree
senior / high school qualification or equivalent
What is their Ethnicity
Arab
Bangladeshi
Black African
Black British
Caribbean
Chinese
Indian
Kurdish
Mixed/Multiple: White and Asian
Mixed/Multiple: White and Black African
Mixed/Multiple: White and Black Caribbean
Pakistani
Turkish
White: English, Welsh, Scottish, Northern Irish or British
White: Gypsy or Irish Traveller
White: Irish
Any other Asian background
Any other Black, African or Caribbean background
Any other ethnic group
Any other Mixed or Multiple ethnic background
Any other White background
What is their Gender
Male
Female
Non Binary
Prefer not to say
What is their Role
Service User
Volunteer
External/Referral Organisation
What is your country of birth?
Northern Ireland
England
Republic of Ireland
Scotland
Wales
Prefer not to say
Elsewhere (please tell us where)
What is your current employment status?
Employed
Not employed seeking work
Not employed not seeking work
What is your current situation?
In full-time education
In employment (under 16 hours)
In employment (over 16 hours)
Not in education, employment or training
Other
What is your Favourite colour?
Green
Red
Blue
Yellow
What is your gender identity?
Male
Female
What is your geographical location?
Africa
Africa- East
Africa- North
Africa- South
Africa- West
Americas
Asia Pacific
Australia / New Zealand
Canada
Europe
Europe- East
Europe- Mediterranean
Europe- North
Europe- West
Europe and Russian
Indian Sub-continent
Latin America
Middle East
North America
South america
United Kingdom
What is your highest level of education completed?
High school diploma or equivalent
GCSE
A-level
Additional Courses
What is your highest Level of Qualification?
None
Entry Level
Level 1 (GCSEs grades 3,2,1 or D,E,F,G) Music grades 1,2,3
Level 2 (CSE grade 1, GCSE 9,8.7.6.5.4 or A*, A, B, C or Olevel A,B,C)
Government-registered nonprofit - able to provide tax receipts in your country
Government registered nonprofit - unable to provide tax receipts
Unregistered organizations (community based grassroots)
Other
What is your personality
Introverted
Extroverted
Ambiverted
What is your religion or belief?
No religion or belief
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Prefer not to say
Other
What is your sex?
Female
Male
Other
What is your sexual orientation?
Heterosexual
Gay
Lesbian
Bisexual
Asexual
Pansexual
Undecided
Prefer not to say
Other
What kinds of activity or project would you be happy to participate in through the Advisor Network? All activities will be supported by Buttle UK staff and you will be given full briefings, support and (where needed) training to participate.
Surveys
Research interviews
Online meetings about specific issues
Online consultation events (up to half a day)
In-person consultation events (half or full day)
Writing about your experiences for our media/campaigns work
Speaking to journalists about your experiences
Speaking at Buttle UK events (online or in person)
Projects (e.g. a few meetings over 3-6 months to work through an issue)
Creating resources, guides, videos etc
Being on recruitment panels for new Buttle UK staff
Giving feedback on new ideas/documents/social media campaigns etc
Other
What made you want to come?
It is near my home
I was intrigued, this is new for my area
I wanted to meet new people in my community
I like the idea behind Thank You day
I liked the event idea
What meals do you eat daily?
Breakfast
Lunch
Teatime
Dinner
Late evening food
What method of transport will you be using for your volunteering?
Car
Bus
Cycling
Walking
What practitioners are currently working with the child? Please select all that apply
