About you

Name

Postcode

Email address

Tick if you’d like to be kept informed of progress on our SIP and other news and events from Western Gateway

Tick here

Please tell us in what capacity you are responding to this survey

Member of public

On behalf of a public sector organisation

On behalf of a private sector organisation

On behalf of a charitable or community group

Other

Age

15 or under

16 to 17

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 75

76 and over

Prefer not to say

How would you describe your ethnic background?

Arab

Asian/Asian British – Bangladeshi

Asian/Asian British – Indian

Asian/Asian British – Pakistani

Asian/Asian British – Chinese

Asian/Asian British – Other (please state)

Black/African/Caribbean/Black British – African

Black/African/Caribbean/Black British – Caribbean

Black/African/Caribbean/Black British – Other (please state)

Gypsy or Traveller of Irish Heritage

Mixed/Multiple Ethnic Groups – White & Asian

Mixed/Multiple Ethnic Groups – White & Black African

Mixed/Multiple Ethnic Groups – White & Black Caribbean

Mixed/Multiple Ethnic Groups Other (please state)

White – English/Welsh/Scottish/ Northern Irish/British

White – Irish

White – Other (please state)

Other ethnic group (please state)

Prefer not to say

Which of the following best describes how you think of yourself?

Man (inc Trans man)

Woman (inc Trans woman)

Non-binary/gender-fluid

In another way

Prefer not to say

Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months? Include problems due to old age?

Yes, limited a lot

Yes, limited a little

No

Prefer not to say

If yes, which of these conditions best describe your health issues or disability?

Vision (e.g. blindness or partial sight)

Hearing (e.g. deafness or partial hearing)

Mobility (other than wheelchair user)

Wheelchair user

Dexterity (difficulty in using your hands and wrists)

Stamina or breathing or fatigue

Memory

Learning or understanding or concentrating

Mental health (e.g. depression, bipolar)

Anxiety (e.g. phobias, generalised anxiety, social anxiety)

Other disability, please specify

Prefer not to say

For which of these purposes do you travel in the Western Gateway region regularly (at least once a week)?

Tick all that apply

I live here

Attend education

Attend employment

Work/professional visits

Leisure

Shopping

Visiting friends or relatives

Which of the following modes of transport do you use regularly (at least once a week)?

Walking or wheeling (including mobility scooters)

Bike (all types, including eBikes)

Scooter or eScooter

Bus

Demand responsive or community transport

Train

Motorbike or moped

Car or van (as driver)

Car or van (as passenger)

Large vehicle (e.g. HGV, tractor)

We anticipate reviewing our Strategic Investment Plan in around 12 months' time. At this time, we would like to invite proposals from a wider range of stakeholders. If you have suggestions of organisations we should contact please enter them here

Your personal information is captured, held and processed by Participatr Limited for the purposes of this project only. Participatr Limited has created and launched this engagement platform on behalf of West of England Mayoral Combined Authority, and we collectively make decisions about how personal information is captured, held, processed and analysed, meaning that we are joint data controllers for the purposes of the General Data Protection Regulation.

Your name is used to identify you as a single respondent. Your remail address is used to send you news and information about this project. Your postcode is used to analyse the broad location of respondents and will not be used to contact you in any way. All of your personal information is held in a secure database on a server located in the United Kingdom. For more information about how we use your personal information, please visit our privacy policy.

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