Member self-assessment form
Membership of the Croydon adult social service user panel (CASSUP) is a
very responsible and important role. To help you decide if it’s for you, we have
listed the key qualities and experience you will need in order to do the role
effectively. Please complete the form and, where indicated, give an example.
This can be either work related or something from your personal life.
Induction and training will be provided and there will be support from the
resident involvement team.
Post code:
Telephone number:
Email address:
Qualities and experience I have Yes No Not
Are you a resident of Croydon, or a carer for a resident
of Croydon?
Are you (please tick one of the following three options)
A Croydon adult social service user or
A carer of a Croydon adult social service user or
Actively concerned about improving Croydon adult
social services for service users
I can commit the time needed to make the CASSUP a
success at least 3 hours per month
I am willing to participate in the training sessions
I am able to work well as part of a group and contribute
to group discussions
Please give details below of an example of group work you have taken
part in, including what you did (this can be paid or volunteer work, helping
a play group, joining a book club etc.)
Yes No Not
I can think objectively about the task in hand and not
promote my personal interests
I am able to read and understand documents and then
give my view or opinion to a wider group
I have good written or verbal communication skills
I have good listening skills and am prepared to listen to
other peoples’ points of view
I am prepared to familiarise myself and abide by the
code of conduct for the panel and uphold the integrity of
the panel at all times
I understand and am committed to upholding the
principles of equalities and diversity
I will uphold confidentiality regarding any commercially
sensitive or personal information that I may handle in
connection to the panel
I will act in a professional, diplomatic and sensitive
manner in all dealings with the panel and officers and
contractors of Croydon Council
I will strive to make positive improvements to the service
in partnership with the Council
Please use this space to give details of any other experience or
knowledge you have that you think is relevant to this role:
Please use this space to say why you want to get involved with CASSUP
To assist us with our monitoring and equalities information, please complete
the sections below:
Please indicate your age group:
Panel members must be aged 18 or over
18 – 35 years 36 – 65 years Over 65 years
Please indicate whether any of the following applies:
Learning disability Physical disability
Mental health issues Deaf or hard of hearing
Visually impaired Other, including carers
Please give further details below if you have ticked any of the above
Please indicate your gender:
Male Female Transgender
Please indicate your race:
Asian Black White
Other (please give detail)
Religious/faith groups:
Buddhist Christian Hindu Jewish
Muslim Sikh No religion/faith
Other (please give detail)
Sexual orientation:
Heterosexual Lesbian Gay Bisexual
Please send your completed form to:
Croydon Council
Department of adult services, health and housing
Resident involvement & scrutiny team
Floor 3, zone A
Bernard Weatherill House
8 Mint Walk
Croydon, CR0 1EA
Or save this completed document and email it to
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