Member type	Public Staff
Title	Unspecified Mr Mrs Miss Ms Mx Dr Professor Canon Wing Commander Reverend Rabbi Capt Col Father Major Commodore Cllr Sister Master Lady Mayor Sir Hon Nurse
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Preferred method of contact	Email Post Telephone SMS
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
Faith	Not Stated Christianity Judaism Islam Buddhism Hinduism Sikhism Agnostic Atheist Other (please state) No Religion
Sexual Orientation	Not Stated Heterosexual Homosexual Bisexual Transgender

Special Postal Requirements	Audio tapes Braille Large Print Other (please list in ‘Notes’ section)
Disabilities	No Yes A learning difficulty A mental health problem A physical disability A sensory disability Any other disability or special need
What level of membership would you like?	Completed questionnaire Informed (receiving newsletter,invitation to annual members' meeting,opportunity to comment on future plans) Involved (as Informed plus invitation to attend events,talks on topics about health issues and hospital developments) Active (as Involved plus invitation to take part in focus groups/special interest groups) Interested in becoming a governor
Service preferences?	Accident and Emergency Cancer Care Children's Services (e.g. Health Visiting, School Nursing) Clinical Support (e.g. x-rays, scans, pharmacy etc) Community Services Critical Care Dental and Oral Health Dermatology Diabetes District Nursing Ear, Nose and Throat (including Audiology) Elderly Care Heart Care Hospital Environment Improving Future Communications Intestinal Failure Neurosciences Orthopaedics Other Outpatients Pain Services Physiotherapy Podiatry Renal Research and Clinical Trials Respiratory Rheumatology Sexual Health Stroke Services Surgery Urology Volunteering
How are you connected with the Trust?	Salford Royal Staff Pennine Acute Staff Patient/Former Patient Relative/Carer Volunteer Employee Former Employee General Public/No Specific Connection Work Experience Veteran
How did you hear about the Trust?	Advertising Face-to-Face Recruitment NCA Website Patient Mailing Through an employee of the Trust Twitter Link Work Experience Student Recruitment Volunteering Other

Member type
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country	UK
Home telephone
Mobile
Email
Ethnicity
Faith
Sexual Orientation
Special Postal Requirements
Preferred method of contact
Disabilities
What level of membership would you like?
Service preferences?
How are you connected with the Trust?
How did you hear about the Trust?

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