1. On what date did you visit the Emergency Department (A&E)?

3. What do you feel has been good about the care or experience you have received ?

4. Do you want to tell us anything else about your visit and what we could improve ?

5. Please confirm that you are happy for us to publish your comments anonymously ?

Yes No

7. What age group are you in ?

0 - 5 years 6 - 17 years 18 - 25 years 26 - 35 years 36 - 45 years 46 - 55 years 56 - 64 years 65 - 74 years 75 - 84 years 85 years + Prefer Not to say

8. Are your day-to-day activities restricted due to a health problem, disability or other impairment which has lasted, or is expected to last, at least 12 months (include any problems related to old age)?

Yes, limited a lot Yes, limited a little No Prefer not to say

9. Please indicate your health condition, disability or other impairment and tick all sections which apply:

Vision (e.g. due to partial sight or blindness) Hearing (e.g. due to partial hearing or deafness) Mobility, such as difficulty walking short distances, climbing stairs, lifting and carrying objects Learning, concentrating or remembering Mental Health Stamina or breathing difficulty Social or behavioural issues (e.g. due to neuro diverse conditions such as Autism, Attention Deficit Disorder or Asperger’s Syndrome) Other impairment, health condition or disability; Prefer not to say

10. What is your ethnic group? Tick the appropriate box to indicate the patient ethnic group.

Please type the first few letters... White - Welsh / English / Scottish / Northern Irish / British White - Irish White - Gypsy or Irish Traveller Any other White background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Any other mixed background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Pakistani Asian or Asian British - Chinese Asian or Asian British - any other background Black or Black British - Carribean Black or Black British - African Black or Black British - Any other black background Other ethnic Group - Arab Any other Prefer not to say

11. Which of the following best describes your gender?

Male Female Non-binary Prefer not to say In your own words

12. What is your first language

13. Trans is an umbrella term to describe people whose gender is not the same as the sex they were assigned at birth. Do you consider yourself to be a trans person?

Yes No Prefer not to say In your own words

14. Which of the following best describes your sexual orientation?

Heterosexual / straight Gay woman / lesbian Gay man Bi / bisexual Prefer not to say In your own words

15. What is your legal marital or civil partnership status?

Single Living with partner Married or in a registered civil partnership Separated, but still in a registered civil partnership or legally married Divorced or formerly in a registered civil partnership which is now dissolved Widowed or surviving partner from a registered civil partnership Prefer not to say

16. What is your faith or belief?

No recognised faith or belief Buddhist Hindu Jewish Sikh Atheist Christian Humanist Muslim Prefer not to say Any other religion

17. Do you look after, or give any help or support to family members, friends, neighbours or others because of either long-term physical or mental ill-health / disability, or problems related to old age?

Yes No Prefer not to say

18. Are you a veteran, including National Service, or do you have a connection to the Armed Forces?

Yes No Prefer not to say