Share your feedback on local health and social care services If you would prefer to speak to a member of staff over the telephone you can call us on 01706 249575 What type of service would you like to tell us about? * GP services NHS Dental services Pharmacy services Mental health support Hospital inpatient (day treatment or overnight) Hospital outpatients’ appointments Accident and emergency/minor injury units Ambulances and paramedics Care home services Home care services NHS 111 Other Issue/Service Please tell us the name of the service * Please tell us about your experience * First name Last name Your email address How did you hear about us? Tell us a bit about you By telling us more information about yourself, you will help us better understand how people's experiences may differ depending on their personal characteristics. However, if you do not wish to answer these questions you do not have to. Please tell us which age category you fall into - None -0 -1213 to 1516 to 1718 to 2425 to 4950 to 6465 to 7980+Prefer not to say Please tell us which gender you identify with - None -WomanManNon - binaryIntersexPrefer not to say Is your gender the same as the sex you were assigned at birth? Yes No Prefer not to say Please tell us which sexual orientation you identify with? - None -AsexualBisexualGay ManHeterosexual/StraightLesbian / Gay womanPansexualPrefer not to sayOther Please select your ethnicity from below - None -ArabAsian / Asian British: BangladeshiAsian / Asian British: ChineseAsian / Asian British: IndianAsian / Asian British: PakinstaniAsian / 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: Black African and WhiteMixed / Multiple ethnic groups: Black Caribbean and WhiteMixed / Multiple ethnic groups: Any other Mixed / Multiple ethnic backgroundWhite / British / English / Welsh / Scottish / Northern IrishWhite: IrishWhite Gypsy, Traveller or Irish TravellerWhite RomaWhite: Any other White backgroundAny other ethnic groupPrefer not to say Do you consider yourself to have a disability? Yes No Prefer not to say Disability Sensory impairment Learning disability or difficulties Mental health condition Physical or mobility impairment Long term condition Other Prefer not to say Do you consider yourself to have a long term health condition? Yes No Prefer not to say Long Term Conditions 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 Prefer not to say Do you consider yourself to be a carer? Yes No Prefer not to say Please pick the area that best describes where you live - None -Rochdale NorthRochdale SouthHeywoodMiddletonPenninesCan we stay in touch? We'd love to tell your story and keep you updated about our work and the difference sharing your experiences with us can make. You can change your mind anytime by clicking unsubscribe on any of our emails. Let us know if you'd be happy for us to stay in touch I would be happy for Healthwatch Rochdale to contact me about using my story as a case study for media purposes I would be happy for Healthwatch Rochdale to email me about advice and information, latest news, research and updates How we use this information The information you have provided will be treated as confidential and used for research purposes. Information may be shared anonymously with Healthwatch England or other health and social care practitioners. If we have asked for personal information that allows you to be identified this information will only be used for the purpose you have given us permission for.. 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. Find out more about how we handle your information in our privacy statement. Consent * I agree to my personal data being used and stored by Healthwatch. Tick this box if you're happy to give consent for your information to be used as outlined above. Submit
