Signing Up For Involvement - Survey Thank you for continuing to be involved in the development of health and care services across Bristol, North Somerset and South Gloucestershire (BNSSG). Your views are important to us.In order that we can contact you about subjects that are relevant to you, please complete this short questionnaire.Anything you tell us will be kept anonymous and will be securely stored on Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group's, (BNSSG CCG's), systems, including our SurveyMonkey account. For more information please refer to our privacy policy. OK Question Title * 1. Would you like to opt in to receive information from BNSSG CCG? Yes No OK Question Title * 2. Where do you live? Please enter the first half of your postcode (eg BS12) OK Question Title * 3. Please enter your contact details: Name * Company/Organisation Postal address Address 2 City/Town County Postal Code Email address * Phone Number OK Question Title * 4. Please tell us your preferred method of contact. You can select more than one option: Email Phone Post OK Question Title * 5. What are your interests? Please tick any of the following boxes if you would like to receive information on or take part in consultations on any of the following subjects. Primary Care (eg GP practices) Acute and Emergency Care (eg Hospitals) Community Services (eg voluntary sector, walk in clinics etc) Cancer Planned Care Finance and Budgets Continuing Care (eg care packages, care in the home and care homes etc) Mental health and learning disabilities CCG Corporate and Management Issues Special Projects General information OK Question Title * 6. Would you be prepared to take part in any of the following? Please tick all that apply Receiving regular newsletters Taking part in workshops and discussion groups Completing surveys and questionnaires Being part of a special interest group that relates to your own interests OK Question Title * 7. In addition, would you be happy for our Healthier Together programme office to occasionally contact you with news and information? Healthier Together is our local Sustainability and Transformation Partnership (STP) for Bristol, North Somerset and South Gloucestershire. The CCG is a key partner in this work. Yes No OK The next set of questions is to make sure we consult and communicate with people from all groups in the area and from all communities. The answers to these questions will help us improve the health of the whole local population. All the information you provide will be treated confidentially. OK Question Title * 8. Age group 16-18 19-24 25-34 35-44 45-54 55-64 65-74 75-84 85 + OK Question Title * 9. Do you consider yourself to be a disabled person? Yes No Prefer not to say OK Question Title * 10. If you answered 'yes' to Question 8: It helps us to know whether we are including all people who see themselves as disabled or who have a long-term impairment or condition. Please tick the relevant impairment (disability) group below. You may tick more than one box if appropriate: Physical impairment Sensory impairment Learning disability/ difficulty Mental health condition Long-standing illness/ long-term condition OK Question Title * 11. What is your ethnic group? Asian or Asian British Black, African, Caribbean or Black British Mixed/ Multi ethnic group White British (including English, Welsh, Scottish, Northern Irish or British) White Irish Gypsy, Roma or Irish Traveller Other White (including, East European, Australian or White American) Any other ethnic group (including Arab). Please state below. Prefer not to say If you selected any other ethnic group, please state: OK Question Title * 12. Do you have a Religion or Belief? Yes No Prefer not to say OK Question Title * 13. If you answered 'yes' to Question 11, are you: Christian Buddhist Hindu Jewish Muslim Sikh Pagan Atheist Any other religion or belief (please state below) No religion or belief Prefer not to say If you selected any other religion or belief, please state: OK Question Title * 14. Are you: Female Male Intersex Other (please state below) Prefer not to say If you selected other, please state: OK Question Title * 15. Which of the following options best describes how you think of yourself? Heterosexual or Straight Gay Lesbian Bisexual I don’t know/ I’m not sure Prefer not to say Other sexual orientation not listed. Please state: OK DONE