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* 1. Which of the following 0-19 services would you like to give us some feedback on? (Choose one)

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* 2. Do you remember the name of the professional you saw?

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* 3. Did you find it easy to talk to the staff member you saw?

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* 4. Did you feel listened to by the staff member you saw?

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* 5. Have you been given enough information about regarding care about yourself or your baby/child/family?

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* 6. Only new mothers to complete: I was asked how the whole family are adjusting to the new baby. (Leave blank if you are not a new mother with a baby under 6 months)

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* 7. Do you feel involved in decisions about your care, for your baby, child and/or family's care? 

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* 8. How likely are you to recommend our service to family and friends?  

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* 9. Do you feel the health professionals involved in your care, your baby's, child's, family's care talk together enough?

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* 10. What do you think we can do to improve the care we offer?

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* 11. Any other comment or information you would like to share with us?

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* 12. Would you like to be involved in our patient participation and experience work? This could involve taking part in some interviews and possibly group experiences to hear your story about your care, discuss plans and be involved in shaping future service delivery

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* 13. If you answer yes to question 11, please give us your first name and an email contact address or telephone number that we can contact you on here:

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* 14. THE 9 PROTECTED CHARACTERISTICS - MONITORING CATEGORIES
We are keen to collect equality information as this helps us to understand how our policies and services affect various sections of the communities we serve.  This information helps us to identify inequalities in our service provision and to take action to tackle this if we need to.

The information you provide will be held in the strictest confidence and only be used for the purposes stated above.

Age

What is your age?

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* 15. Disability

Do you consider yourself to have a disability according to the terms given in the Equality Act 2010?
(Under The Equality Act 2010, a person is disabled if they have a physical or mental impairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities, which would include things like using a telephone, reading a book or using public transport.)

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* 16. If yes above please state the type of impairment that applies to you
(People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘Other’ and specify the type of impairment.)

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* 17. Gender

Which of the following describes how you think of yourself?

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* 18. Do you have the protected characteristic Gender-Reassignment

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* 19. Religion and Belief

What is your religious belief?

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* 20. Sexual Orientation

How would you define your sexual orientation

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* 21. Ethnicity

Please note that this question does not refer to your nationality/ country of origin. These categories are based on the 2011 Census categories but include categories to reflect the communities of Tower Hamlets.


I would describe my ethnic origin as:-

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* 22. Relationship Status

How would you state your relationship status

0 of 22 answered
 

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