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Digital Support Devices Form
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10
Questions
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1
Name
*
This field is required.
First Name
Last Name
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2
In which part of the city do you live?
*
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Adamsdown
Birchgrove
Butetown
Caerau
Canton
Cathays
Creigiau
Cyncoed
Ely
Fairwater
Gabalfa
Grangetown
Gwaelod Y Garth
Heath
Leckwith
Lisvane
Llandaff
Llandaff North
Llanederyn
Llanishen
Llanrumney
Maindy
Mynachdy
Pentrebane
Pentwyn
Pentyrch
Penylan
Pontprennau
Radyr & Morganstown
Rhiwbina
Riverside
Roath
Rumney
Splott
St Fagans
St Mellons
Thornhill
Tongwynlais
Tremorfa
Trowbridge
Whitchurch
Adamsdown
Birchgrove
Butetown
Caerau
Canton
Cathays
Creigiau
Cyncoed
Ely
Fairwater
Gabalfa
Grangetown
Gwaelod Y Garth
Heath
Leckwith
Lisvane
Llandaff
Llandaff North
Llanederyn
Llanishen
Llanrumney
Maindy
Mynachdy
Pentrebane
Pentwyn
Pentyrch
Penylan
Pontprennau
Radyr & Morganstown
Rhiwbina
Riverside
Roath
Rumney
Splott
St Fagans
St Mellons
Thornhill
Tongwynlais
Tremorfa
Trowbridge
Whitchurch
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3
What age group are you in?
1-15
16-25
26-35
36-45
46-60
61-74
75+
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4
Please provide us with a contact number
Area Code
Phone Number
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5
Please provide your email address
example@example.com
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6
Do you have access to a tablet or similar device such as a smartphone?
*
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YES
NO
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7
What device do you have?
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8
Do you have access to the internet?
*
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YES
NO
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9
Are you able to effectively make use of basic computer skills such as sending an email or downloading an application?
*
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YES
NO
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10
Do you receive any type of benefits?
YES
NO
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11
Please specify
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12
Are you in receipt of any benefits?
*B3 - Does not relate to savings element of Pension Credit. **B13 - Does not relate to council tax reductions such as single person discount
B3 – Income Support/ Pension Credit*
B4 - Working Tax Credit
B5 – Jobseekers Allowance
B6 – Housing Benefit
B7 –Severe Disability Allowance
B8 – Disability Living Allowance
B9 – Employment Support Allowance (ESA)
B10 – Industrial Injuries Benefit
B11 – Carer’s Allowance
B12 – Incapacity Benefit
B13 – Council Tax Benefit Reduction**
B14 – Personal Independence Payment (PIP)
B15 – Universal Credit
I do not receive a benefit payment
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