Carer involvement questionnaire

Name*

Address*

Postcode*

Email*

Telephone Number*

Audit of carers' information

Please tell us about:

Who you are caring for*

Their age*

How long you have been caring*

How many hours each week you spend caring*

Their relationship to you (e.g. spouse, child, friend)*

Their condition(s) (e.g. long term condition, dementia, mental ill health, learning disability)*

Audit of particular interests, knowledge, experiences

You may have particular interests, skills, knowledge, experiences or expertise in your caring role which you would be willing to discuss or share with others. To help you think about this, we have put some general headings below.

Interests (e.g. NHS, welfare reform, a particular disability)

Experiences (e.g. health services, social care, education, employment)

Skills, knowledge or expertise (e.g. public speaking, talking to small groups)

With which of the following would you be willing to share your experiences, views and opinions (select all that apply) (required)
 With staff members at Carer Support With other carers With others in small working groups or meetings With a statutory/government organisation The press or media

Contact and meetings

Please tell us how you would prefer us to contact you (select all that apply)*
 Telephone Email Letter Home visit Formal meeting

If willing to attend meetings or presentations, how far would you be prepared to travel? (select all that apply)*
 Up to 5 miles from your home Up to 10 miles from your home Up to 20 miles from your home Anywhere in Wiltshire

* denotes required field