Name*

Contact address*

Postcode*

Telephone number

E-mail address

School name

DCSF number (if known)

Area* Please select an area Area 1 (Basingstoke, Fleet, Yateley) Area 2 (Alton, Farnborough, Petersfield) Area 3 (Havant, Waterlooville) Area 4 (Fareham, Gosport, Lee-on-Solent) Area 5 (Winchester, Eastleigh) Area 6 (Hythe, Lymington, Ringwood) Area 7 (Andover, Romsey, Whitchurch)

What is your suggestion, complaint or compliment?

For complaints - how has this affected you?

Have you discussed this matter with a member of Governor Services' staff before filling in this form? If so, who did you speak to and what was the response?

What would you like to happen as a result of contacting us?

Would you like to be contacted about this form?* Yes No

How would you like to be contacted? Post E-mail Telephone

Disabled Yes No

If yes, please could you tick any of the following descriptions that may apply to you: Mobility difficulty Hearing difficulty Difficulty seeing Learning difficulty Mental health issues Other

This information will be handled sensitively to ensure you are supported appropriately.

Hampshire County Council adheres to an equal opportunities and equalities policy and we would appreciate it if you could select the information appropriate to you:

Gender Male Female

Age group Please select... 18-30 31-50 51-65 65+

Ethnic origin Please choose one... British Irish Any other white background White and Black Caribbean White and Black African White and Asian Any other mixed background Indian Pakistani Bangladeshi Any other Asian background Caribbean African Any other black background Chinese Any other