Carers Survey | Healthwatch North Lincolnshire

Contact Us

This field is hidden when viewing the form

Date of Initial Contact(Required)

DD slash MM slash YYYY

This field is hidden when viewing the form

Method of Contact(Required)

Please tell us why you want to contact Healthwatch(Required)

I want to share an experience

I want to request information / advice

I want to enquire about volunteering

My query is none of the above

This field is hidden when viewing the form

Information Questions

Healthwatch has a dedicated volunteering section on our website. If you have not yet viewed this, you can find out more by clicking here.

If you still have any further questions, please let us know below.

Please can you provide more information so we can respond to your query(Required)

This field is hidden when viewing the form

I want to share an experience

Service Type

What is the name of the service?

When did your experience occur? (If known)

Day

Month

Year

Who does this experience belong to?(Required)

Self

Someone else

What is your relationship to this person?(Required)

Client relative, Friend or Carer

Health or Social Care Professional

Other third party

Please can you tell us about the experience?(Required)

What is the nature of your experience?(Required)

Concern

Complaint

Compliment

Whistleblowing

Do you consider the experience to be a safeguarding issue?(Required)

Yes

Basic Demographics

Healthwatch collects demographic data which is used to generate insights and understand health inequalities, including challenges some groups face in accessing health and social care services.

As part of your experience, we would like you to provide some basic demographic data below to help us in our mission to improve local services.

What is your age range?(Required)

What is your ethnicity?(Required)

Are you or do you consider yourself to be disabled?(Required)

Yes

Do you or do you consider yourself to have a long-term condition?(Required)

Yes

This field is hidden when viewing the form

Section Break

Thank you for completing the above demographic questions.

We do also record more detailed demographic information which will help us further, however this is completely optional.

Would you like to provide any further demographic information?(Required)

Yes

This field is hidden when viewing the form

Section Break

Please can you tell us your nationality?

Is your gender identity the same as recorded at birth?

What is your sexual orientation?

What is your religion or belief?

What is your marital and civil partnership status?

If you are currently pregnant or have recently given birth, please select if any of the following apply:

Currently pregnant

Currently breastfeeding

Given birth in the last 26 weeks

Would you consider yourself to be from a seldom-heard group or community?

The term 'seldom-heard groups' refers to under-represented people who use or might potentially use health or social services and who are less likely to be heard by these service professionals and decision-makers.

Yes

This field is hidden when viewing the form

If they select that they have a disability

You told us previously that you are or consider yourself to be disabled.

Please could you be able to tell us what type of disability you have?

You can select more than one

Physical or mobility impairment

Sensory impairment

Learning disability or difficulties

Mental health condition

Long term condition

Other

This field is hidden when viewing the form

If they select that they have a long-term condition

You told us previously that you are or consider yourself to be disabled.

Please could you be able to tell us what type of long-term condition you have?

You can select more than one

Asthma, COPD or respiratory condition

Blindness or severe visual impairment

Cancer

Cardiovascular condition (including stroke)

Chronic kidney disease

Deafness or severe hearing impairment

Dementia

Diabetes

Epilepsy

Hypertension

Learning disability

Mental health condition

Musculoskeletal condition

Other

Contacting You

Do you want to be contacted by Healthwatch about your experience?(Required)

Yes

This field is hidden when viewing the form

Contact Details

Please tell us your name(Required)

First Last

Telephone Number

Email Address

If you want to be contacted by letter, please provide your address below

Street Address Address Line 2 City ZIP / Postal Code

Contact Us

This field is hidden when viewing the form

Date of Initial Contact(Required)

DD slash MM slash YYYY

This field is hidden when viewing the form

Method of Contact(Required)

Please tell us why you want to contact Healthwatch(Required)

I want to share an experience

I want to request information / advice

I want to enquire about volunteering

My query is none of the above

This field is hidden when viewing the form

Information Questions

Healthwatch has a dedicated volunteering section on our website. If you have not yet viewed this, you can find out more by clicking here.

If you still have any further questions, please let us know below.

Please can you provide more information so we can respond to your query(Required)

This field is hidden when viewing the form

I want to share an experience

Service Type

What is the name of the service?

When did your experience occur? (If known)

Day

Month

Year

Who does this experience belong to?(Required)

Self

Someone else

What is your relationship to this person?(Required)

Client relative, Friend or Carer

Health or Social Care Professional

Other third party

Please can you tell us about the experience?(Required)

What is the nature of your experience?(Required)

Concern

Complaint

Compliment

Whistleblowing

Do you consider the experience to be a safeguarding issue?(Required)

Yes

Basic Demographics

Healthwatch collects demographic data which is used to generate insights and understand health inequalities, including challenges some groups face in accessing health and social care services.

As part of your experience, we would like you to provide some basic demographic data below to help us in our mission to improve local services.

What is your age range?(Required)

What is your ethnicity?(Required)

Are you or do you consider yourself to be disabled?(Required)

Yes

Do you or do you consider yourself to have a long-term condition?(Required)

Yes

This field is hidden when viewing the form

Section Break

Thank you for completing the above demographic questions.

We do also record more detailed demographic information which will help us further, however this is completely optional.

Would you like to provide any further demographic information?(Required)

Yes

This field is hidden when viewing the form

Section Break

Please can you tell us your nationality?

Is your gender identity the same as recorded at birth?

What is your sexual orientation?

What is your religion or belief?

What is your marital and civil partnership status?

If you are currently pregnant or have recently given birth, please select if any of the following apply:

Currently pregnant

Currently breastfeeding

Given birth in the last 26 weeks

Would you consider yourself to be from a seldom-heard group or community?

Yes

This field is hidden when viewing the form

If they select that they have a disability

You told us previously that you are or consider yourself to be disabled.

Please could you be able to tell us what type of disability you have?

You can select more than one

Physical or mobility impairment

Sensory impairment

Learning disability or difficulties

Mental health condition

Long term condition

Other

This field is hidden when viewing the form

If they select that they have a long-term condition

You told us previously that you are or consider yourself to be disabled.

Please could you be able to tell us what type of long-term condition you have?

You can select more than one

Asthma, COPD or respiratory condition

Blindness or severe visual impairment

Cancer

Cardiovascular condition (including stroke)

Chronic kidney disease

Deafness or severe hearing impairment

Dementia

Diabetes

Epilepsy

Hypertension

Learning disability

Mental health condition

Musculoskeletal condition

Other

Contacting You

Do you want to be contacted by Healthwatch about your experience?(Required)

Yes

This field is hidden when viewing the form

Contact Details

Please tell us your name(Required)

First Last

Telephone Number

Email Address

If you want to be contacted by letter, please provide your address below

Street Address Address Line 2 City ZIP / Postal Code