Healthwatch Middlesbrough and Redcar and Cleveland are a patient voice organisation whose role is to listen to, and strengthen the voice of the local community to help improve local health and social care services now, and in the future. We would like to invite you, the local community to share your views on what you feel our priorities should be for 2017/18.

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* 1. Please select three services which you feel should be Healthwatch Middlesbrough and Redcar and Cleveland's top 3 priorities from the list below (Please list them in order 1 to 3, 1 = Highest priority):

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* 2. Are there any other services which are not listed above but you feel should be one of Healthwatch Middlesbrough and Redcar & Cleveland's priorities for 2017/18?

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* 3. Please explain why you rated these particular services as the top 3 priorities for Healthwatch Middlesbrough and Redcar & Cleveland to focus on?

In order to gain a better understanding of our sample base for this survey we would like to ask you a few questions which are optional. The details you provide will not be shared with anyone or any organisation outside Healthwatch Middlesbrough and Redcar & Cleveland to ensure confidentiality and anonymity.

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* 4. What is your gender?

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* 5. Please provide the first half of your postcode (e.g TS6):

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* 6. Please select your age range:

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* 7. Please indicate your ethnicity from the list below:

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* 8. Do you have a long term health condition?

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* 9. Do you consider yourself to have a disability?

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* 10. If you do consider yourself to have a disability, please tick the following that apply to you:

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* 11. Do you care for someone who has a long term health condition or disability?

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* 12. If you would you like to know more about Healthwatch Middlesbrough and Redcar & Cleveland, then please provide your contact details below to join our membership.

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