Tell us what you think!

Healthwatch Harrow want to find out more about you and your experience of local health and social care. This is so we can help make local services better. Please respond to the questions below, and have your say!

Please note, this is a general feedback form which is periodically reviewed. If you would like to raise an urgent issue, please contact us via email on info@healthwatchharrow.co.uk or telephone on 020 3432 2889.

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* 1. Age - What is your age group?

Under 16

16 – 24 years

25 – 44 years

45 – 64 years

65 & over

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* 2. Disability - Do you consider yourself to have a disability or long-term condition?

Yes

Prefer not to say

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* 3. Disability - If you said yes, please tell us about your disability / condition (you can choose one or more answers).

Physical disability

Learning disability

Mental health condition

Other (please specify)

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* 4. Ethnic origin - What is your ethnic origin?

Asian or Asian British

Indian

Sri Lankan

Bangladeshi

Pakistani

Afghan

Chinese

Arab

Iranian

Black or Black British

African

Somali

Caribbean

Mixed White and Black African

Mixed White and Black Caribbean

Mixed White and Asian

White British (including English, Welsh, Scottish and Northern Irish)

Albanian

Gypsy / Irish Traveller

Polish

Romanian

Other including other Asian, Black, Mixed or White backgrounds (please specify)

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* 5. Religion - What is your religion?

Buddhism

Christianity (all denominations)

Hinduism

Islam

Jainism

Judaism

Sikh

Zoroastrian

No religion / Atheist / Agnostic

Other (please specify)

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* 6. Carer status - Are you a carer for a vulnerable person?

Yes

Prefer not to say

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* 7. Sex - Are you?

Female

Male

Prefer not to say

Other (please specify)

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* 8. Gender - Is your gender identity the same as the gender you were assigned at birth? (If you identify as transgender or transsexual, please select ‘No’)

Yes

Prefer not to say

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* 9. Sexual orientation - Are you?

Bisexual

Gay woman / lesbian

Gay man

Heterosexual

Prefer not to say

Other (please specify)

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* 10. Have your say - Please tell us about your health or social care experience below:

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* 11. First Name - What is your first name? (Optional)

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* 12. Last Name - What is your last name? (Optional)

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* 13. Future contact - Would you like to receive our newsletter and information about other Healthwatch Harrow events in future?

Yes

Tell us what you think!

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* 1. Age - What is your age group?

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* 2. Disability - Do you consider yourself to have a disability or long-term condition?

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* 3. Disability - If you said yes, please tell us about your disability / condition (you can choose one or more answers).

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* 4. Ethnic origin - What is your ethnic origin?

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* 5. Religion - What is your religion?

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* 6. Carer status - Are you a carer for a vulnerable person?

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* 7. Sex - Are you?

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* 8. Gender - Is your gender identity the same as the gender you were assigned at birth? (If you identify as transgender or transsexual, please select ‘No’)

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* 9. Sexual orientation - Are you?

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* 10. Have your say - Please tell us about your health or social care experience below:

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* 11. First Name - What is your first name? (Optional)

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* 12. Last Name - What is your last name? (Optional)

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* 13. Future contact - Would you like to receive our newsletter and information about other Healthwatch Harrow events in future?

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* 14. Contact information - If you answered question 13 with a yes, please share your email address.

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* 15. Contact information - What is your phone number? (Optional)