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.

There are details about how we will use your information on the Bristol CCGSouth Gloucestershire CCG and North Somerset CCG websites. It will also be on the new BNSSG CCG website.

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* 1. Would you like to opt in to receive information from BNSSG CCG?

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* 2. Where do you live?
Please enter the first half of your postcode (eg BS12)

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* 3. Please enter your contact details:

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* 4. Please tell us your preferred method of contact.  You can select more than one option:

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* 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.

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* 6. Would you be prepared to take part in any of the following?
Please tick all that apply

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* 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.

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.

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* 8. Age group

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* 9. Do you consider yourself to be a disabled person?

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* 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:

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* 11. What is your ethnic group?

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* 12. Do you have a Religion or Belief?

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* 13. If you answered 'yes' to Question 11, are you:

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* 14. Are you:

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* 15. Which of the following options best describes how you think of yourself?

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