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Ethnicity	Not stated White - English, Welsh, Scottish, Northern Irish, British White - Irish White - Gypsy or Irish Traveller White - Other Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Other Mixed Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Other Asian Black or Black British - African Black or Black British - Caribbean Black or Black British - Other Black Other Ethnic Group - Arab Other Ethnic Group - Any Other Ethnic Group

Special Postal Requirements	Large Print Braille/Audiotranslations Other Easy Read
Disabilities	No Yes A sensory disability A physical disability A learning disability A mental health problem Any other special need (please list in the 'Notes' section) Disabled Longstanding illness
How would you like to be involved?	Consider standing for election as governor Completed questionnaire Provide Feedback Participate in the election of Council of Governors Becoming a Volunteer Receiving Regular Information Attending meetings or events Interest in survey Receive an annual summary report
Service preferences?	Accident and Emergency Back Problems Cancer Children's Health Children's services Dental Dermatology Diabetes Ear, Nose and Throat Elderly Care Epilepsy Eye Problems General Haematology Heart Disease Hospital Cleanliness/Environment Hospital Food Immune system conditions Intestinal Conditions Kidney and Liver Problems Medicine Men's Health National Spinal Injuries Centre Neurology Other Outpatient services Pain Sexual Health Surgery Therapies Women's health
How are you connected with the Trust?	A current patient A past patient Support Worker Volunteer for Trust Work for Trust (KCL Staff Only)
How did you hear about the Trust?	Online Application Public meetings Public consultation mailing Other

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