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Data Collection Wizard
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Welcome to the Healthwatch Feedback and Signposting Data Collection Wizard.
Please enter details of the enquiry below.
Description of the enquiry:
Date incident took place (if known)
Date information collected by Local Healthwatch
Date information collected by Local Healthwatch: Date
Date information collected by Local Healthwatch: Time
Details:
Summary
Max 127 characters
Activity Location
Non CPI / PII information box
CPI / PII information box
Select feedback or information type
Telephone
Email
Website Feedback
Meeting
Social Media
Post
Research
Third Party
Visit to provider
Not known
Engagement Event
Guidance / Advice
Which was the primary research method used?
Consultation
Deliberative event
Engagement event
Focus group
Observation
Structured Interview
Survey
Semi Structured Interview
User stories
Event Details
Is this a safeguarding issue?
Yes
No
Not Applicable
Not Known
Safeguarding details
Personal views
Personal views:
Does the information include service user's views?
Yes
No
Does the information include carer's, friend's or relative's views?
Yes
No
Does the information include LHW staff's or external staff's views?
Yes
No
Have any other people included their views?
Yes
No
Outcome:
Is the outcome of the enquiry already known?
No
Yes
Outcome Details
Has action been taken?
None
Yes
No
N/A
Person who received the care
Details collected:
Collect anonymous details
Collect personal details
Has the person receiving the care given you permission in accordance with the Data Protection Act 2018 to store their details?
Yes
No
Person who received the care
Personal details:
This information is not sent to Healthwatch England but is stored on your local system.
Existing Contact
First Name
Last Name
Phone Number
Email
Website
Website Type
Main
Work
Facebook
Twitter
Personal
Google+
Instagram
LinkedIn
Pinterest
Tumblr
SnapChat
Vine
Street Address
Street Address Line 2
City
County
- None -
Aberdeen City
Aberdeenshire
Angus
Antrim and Newtownabbey
Ards and North Down
Argyll and Bute
Armagh City, Banbridge and Craigavon
Bedfordshire
Belfast
Berkshire
Blaenau Gwent
Bridgend
Bristol, City of
Buckinghamshire
Caerphilly
Cambridgeshire
Cardiff
Carmarthenshire
Causeway Coast and Glens
Ceredigion
Cheshire
Clackmannanshire
Clwyd
Co Antrim
Co Armagh
Co Down
Co Fermanagh
Co Londonderry
Co Tyrone
Conwy
Cornwall
County Durham
Cumbria
Denbighshire
Derbyshire
Derry City and Strabane
Devon
Dorset
Dumfries and Galloway
Dundee City
Dyfed
East Ayrshire
East Dunbartonshire
East Lothian
East Renfrewshire
East Riding of Yorkshire
East Sussex
Edinburgh, City of
Essex
Falkirk
Fermanagh and Omagh
Fife
Flintshire
Glasgow City
Gloucestershire
Greater Manchester
Gwent
Gwynedd
Hampshire
Herefordshire
Hertfordshire
Highland
Inverclyde
Isle of Anglesey
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
Lisburn and Castlereagh
London
Merseyside
Merthyr Tydfil
Mid and East Antrim
Mid Glamorgan
Mid Ulster
Midlothian
Monmouthshire
Moray
Na h-Eileanan Siar
Neath Port Talbot
Newport
Newry, Mourne and Down
Norfolk
North Ayrshire
North Lanarkshire
North Yorkshire
Northamptonshire
Northumberland
Nottinghamshire
Oldham
Omagh
Orkney Islands
Oxfordshire
Pembrokeshire
Perth and Kinross
Powys
Renfrewshire
Rhondda, Cynon, Taff
Rutland
Scottish Borders
Shetland Islands
Shropshire
Somerset
South Ayrshire
South Glamorgan
South Gloucestershire
South Lanarkshire
South Yorkshire
Staffordshire
Stirling
Suffolk
Surrey
Swansea
Torfaen
Tyne and Wear
Vale of Glamorgan, The
Warwickshire
West Dunbartonshire
West Glamorgan
West Lothian
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Wrexham
Country
United Kingdom
Postal Code
Anonymous details of person who received the care:
Further details of person who received the care:
This information is sent to Healthwatch England anonymously.
Basic Details
Age
- Age -
0 to 12 years
13 to 15 years
1-15 years
16-17 years
18 to 24
25 to 49
50 to 64
65 to 79
80+
Not known
Prefer not to say
What is the person's gender?
- Gender -
Intersex
Man
Non-binary
Not known
Prefer not to say
Prefer to self-describe
Transexual
Transgender
Woman
Self-described gender
Is the person's gender identity the same as the sex they were assigned at birth?
- None -
Yes
No
Prefer not to say
Not known
Sexual Orientation
- Sexual Orientation -
Asexual
Bisexual
Gay man
Heterosexual / Straight
Lesbian / Gay woman
Not known
Pansexual
Prefer not to say
Prefer to self-describe
Self-described sexual orientation
Marital Status
- Marital Status -
Cohabiting
Divorced / Dissolved civil partnership
In a civil partnership
Married
Not known
Prefer not to say
Separated
Single
Widowed
Pregnancy and maternity
Currently breastfeeding
Currently pregnant
Given birth in the last 26 weeks
N/A
Not known
Prefer not to say
Ethnicity, Religion or Beliefs
Nationality
Ethnicity
- Select Ethnicity -
Any other ethnic group (please specify)
Arab
Asian / Asian British: Any other Asian / Asian British background (please specify)
Asian / Asian British: Bangladeshi
Asian / Asian British: Chinese
Asian / Asian British: Indian
Asian / Asian British: Pakistani
Black / Black British: African (please specify)
Black / Black British: Any other Black / Black British background (please specify)
Black / Black British: Caribbean
Mixed / Multiple ethnic groups: Any other Mixed / Multiple ethnic groups background (please specify)
Mixed / Multiple ethnic groups: Asian and White
Mixed / Multiple ethnic groups: Black African and White
Mixed / Multiple ethnic groups: Black Caribbean and White
Not known
Prefer not to say
White: Any other White background (please specify)
White: British / English / Northern Irish / Scottish / Welsh
White: Gypsy, Traveller or Irish Traveller
White: Irish
White: Roma
Ethnicity - Please Describe
Religion or Belief
- Religion or Belief -
Buddhist
Christian
Hindu
Jewish
Muslim
No religion
Other religion
Prefer not to say
Sikh
Unknown
Other religion
Disability or Condition
Disability
Sensory impairment
Learning disability or difficulties
Mental health condition
Physical or mobility impairment
Long term condition
Other
No
Prefer not to say
Not known
Disability - Please Describe
Long Term Condition
Asthma, COPD or respiratory condition
Blindness or severe visual impairment
Cancer
Cardiovascular condition (including stroke)
Chronic kidney disease
Deafness or severe hearing impairment
Dementia
Diabetes
Epilepsy
Hypertension
Learning disability
Mental health condition
Musculoskeletal condition
No
Not known
Other
Prefer not to say
Long Term Condition - Please Describe
Do you consider yourself to be a carer?
- Carer -
Yes
No
Prefer not to say
Not known
Location Information
Postcode prefix
District
Residential Area
Seldom heard
Seldom heard
Yes
No
Type of seldom heard group
Homeless people
People in stigmatised occupations (such as sex workers)
People who are geographically isolated
People who are long-term unemployed
People who live in poverty
People who misuse drugs
People with limited family or social networks
Refugees or asylum seekers
Caller details
Caller details:
What is the relationship to the person involved?
Individual
Client Relative, Friend or Carer
Advocate
Unrelated
Health or Social Care Professional (Nurse, Doctor, Physio, etc)
Local Campaigner
Journalist
Local Councillor
Parliamentarian
Parliamentary or Political Staff International Stakeholder (i.e. Consumer International CEO or UN Official)
Other
If the caller was not the person who received the care, do you wish to store their details
Yes
No
Has the caller given you permission in accordance with the Data Protection Act 2018 to store their details?
Yes
No
This information is not sent to Healthwatch England but is stored on your local system.
Search for an existing contact below. If no existing contact is found you can create a new contact.
First Name
Last Name
Gender
Female
Male
Transgender
Prefer not to say
Phone Number
Email
Website
Website Type
Main
Work
Facebook
Twitter
Personal
Google+
Instagram
LinkedIn
Pinterest
Tumblr
SnapChat
Vine
Street Address
Street Address Line 2
City
State/Province
- None -
Aberdeen City
Aberdeenshire
Angus
Antrim and Newtownabbey
Ards and North Down
Argyll and Bute
Armagh City, Banbridge and Craigavon
Bedfordshire
Belfast
Berkshire
Blaenau Gwent
Bridgend
Bristol, City of
Buckinghamshire
Caerphilly
Cambridgeshire
Cardiff
Carmarthenshire
Causeway Coast and Glens
Ceredigion
Cheshire
Clackmannanshire
Clwyd
Co Antrim
Co Armagh
Co Down
Co Fermanagh
Co Londonderry
Co Tyrone
Conwy
Cornwall
County Durham
Cumbria
Denbighshire
Derbyshire
Derry City and Strabane
Devon
Dorset
Dumfries and Galloway
Dundee City
Dyfed
East Ayrshire
East Dunbartonshire
East Lothian
East Renfrewshire
East Riding of Yorkshire
East Sussex
Edinburgh, City of
Essex
Falkirk
Fermanagh and Omagh
Fife
Flintshire
Glasgow City
Gloucestershire
Greater Manchester
Gwent
Gwynedd
Hampshire
Herefordshire
Hertfordshire
Highland
Inverclyde
Isle of Anglesey
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
Lisburn and Castlereagh
London
Merseyside
Merthyr Tydfil
Mid and East Antrim
Mid Glamorgan
Mid Ulster
Midlothian
Monmouthshire
Moray
Na h-Eileanan Siar
Neath Port Talbot
Newport
Newry, Mourne and Down
Norfolk
North Ayrshire
North Lanarkshire
North Yorkshire
Northamptonshire
Northumberland
Nottinghamshire
Oldham
Omagh
Orkney Islands
Oxfordshire
Pembrokeshire
Perth and Kinross
Powys
Renfrewshire
Rhondda, Cynon, Taff
Rutland
Scottish Borders
Shetland Islands
Shropshire
Somerset
South Ayrshire
South Glamorgan
South Gloucestershire
South Lanarkshire
South Yorkshire
Staffordshire
Stirling
Suffolk
Surrey
Swansea
Torfaen
Tyne and Wear
Vale of Glamorgan, The
Warwickshire
West Dunbartonshire
West Glamorgan
West Lothian
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Wrexham
Country
United Kingdom
Postal Code
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