Take three minutes to share your experiences To understand how we will use your information read the 'How we use this information' at the end of the page.This survey is also available in Easy Read.Complete the survey 1. Choose the area of care you would like to tell us about? GP services Dentist Pharmacies Hospital inpatient (day treatment or overnight) Hospital outpatients' appointments Mental health support Social care eg care homes, and home care Accident and emergency/minor injury units Ambulances and paramedics NHS 111 Other issue/service (if other, please tell us which issue/service you are referring to) Please select the options that you'd like to talk to us about. You can pick more than one. If other, please tell us which issue/service you are referring to 2. Does your feedback apply to a specific service? If so, please tell us which ones(s) and their location e.g. Boots Pharmacy - Tavistock. Please make sure to include the service name, department (if relevant) and location. 3. Please tell us about your experience What went well? What could have been better? 4. How easy was it to access the help and support you needed? - Select -Very goodGoodNeither good nor badPoorVery poorN/A 5. How would you describe your experience of care? - Select -GoodNeither good nor badPoorI had a mixed experienceDon't know/not sureNot applicable 6. In relation to this experience please select what best describes you 6. In relation to this experience please select what best describes you - Select -I’m the person who received the careI am a Care Professional for the person who received the careI am a Carer for the person who received the careI am a Friend of the person who received the careI am a Health Professional for the person who received the careI am a Parent/Guardian for the person who received the careI am a Relative of the person who received the careOther Enter other… 7. How did you hear about us? 7. How did you hear about us? - Select -EmailEventFacebookHealth/Care SettingNewspaper/MagazineRadioTVWord of mouthX (formerly known as Twitter)Other Enter other… Tell us a bit about youIt would really help to know a little more about the person who this experience relates to so that we can better understand how people's experiences may differ. These questions are completely voluntary. If you are happy to share more information please tick here. 8. Please tell us your age - Select -16 to 17 years18 to 24 years25 to 49 years50 to 64 years65 to 79 years80+Prefer not to say 9. Please tell us your gender 9. Please tell us your gender - Select -FemaleMaleIntersexNon-binaryPrefer not to sayPrefer to self-describe Enter other… 10. Is your gender identity the same as your sex recorded at birth? - Select -YesNoPrefer not to say 11. Please tell us which sexual orientation you identify with 11. Please tell us which sexual orientation you identify with - Select -AsexualBisexualGay manHeterosexual / StraightLesbian / Gay womanPansexualPrefer not to sayPrefer to self-describe Enter other… 12. Please select your ethnicity 12. Please select your ethnicity - Select -ArabAsian / Asian British: BangladeshiAsian / Asian British: ChineseAsian / Asian British: IndianAsian / Asian British: PakistaniAsian / Asian British: Any other Asian / Asian British backgroundBlack / Black British: AfricanBlack / Black British: CaribbeanBlack / Black British: Any other Black / Black British backgroundMixed / Multiple ethnic groups: Asian and WhiteMixed / Multiple ethnic groups: Black African and WhiteMixed / Multiple ethnic groups: Black Caribbean and WhiteMixed / Multiple ethnic groups: Any other Mixed / Multiple ethnic groups backgroundWhite: British / English / Northern Irish / Scottish / WelshWhite: IrishWhite: Gypsy, Traveller or Irish TravellerWhite: RomaWhite: Any other White backgroundPrefer not to sayAny other ethnic group Enter other… 13. Please select your religion 13. Please select your religion - Select -BuddhistChristianHinduJewishMuslimSikhNo religionPrefer not to sayAny other religion Enter other… 14. Please tell us your postcode 15. Do you have a long term condition? - Select -YesNoPrefer not to say 16. Do you have a disability? - Select -YesNoPrefer not to say 17. Are you a carer? - Select -YesNoPrefer not to say 18. Which of the following best describes your financial status? - None -I have more than enough for basic necessities, and a large amount of disposable income, that I can save or spend on extras or leisureI have more than enough for basic necessities, and a small amount of disposable income, that I can save or spend on extras or leisureI have just enough for basic necessities and little elseI don’t have enough for basic necessities and sometimes run out of moneyI don't know/prefer not to say How we use this information & Staying in touch If you would like to find out more about how we use the information provided and details on why would would like to stay in touch please tick here. How we use your informationThe information you share with us helps us spot trends to identify areas for improvement. We may use quotes in our reports, but we will not use any information that will identify you.As well as your feedback, we also ask you to volunteer some personal information. This helps us to help us understand how different groups experience local health and social care services and supports our focus on improving equality, diversity and inclusion.If you are sharing information on behalf of another person, make sure that you have their permission to do so, or the information you do share should be anonymous.Find out more about how we handle your information in our privacy statement. Using your story for mediaTo promote our campaigns we use people's stories to show what needs to change. The media (newspapers, radio or TV) ask if we have people who can share their story when we publish a press release about our research. Would you be happy for us to contact you about your experience for media purposes or to use your story as a case study in our communications materials? We won’t pass on your name and contact details to the media without your consent and speaking to you first about what it involves. Are you happy to be contacted? I am happy to be contacted by Healthwatch to discuss whether my story could be a case study for a campaign or to be passed onto the media. I don't want to be contacted by Healthwatch about being a case study for a campaign or for the media. Sign-up to our mailing listSign-up to our mailing list to stay up to date with what people are telling us about health and social care, our advice and information, and our latest reports. You can unsubscribe from our mailing list at any time. Please select I want Healthwatch to email me about advice and information, latest news, research and updates. I do not want Healthwatch to email me about advice and information, latest news, research and updates. If yes, enter your name and email address. Name Email Submit Leave this field blank
