Member type	Public Staff Patient
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Wing Commander Capt Col Major Commodore Cllr Sister Master Lady Mayor Sir Mx
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Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Transgender
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Preferred method of contact	Email Post Telephone SMS
Ethnic Origin	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
Religion/Belief	Not Stated
Sexual Orientation	Not Stated Hetrosexual Gay Man Bisexual Gay Woman (lesbian) Prefer not to say

Special Postal Req	Large Print Audio Braille Other (please list in ‘Notes’ section)
Disabilities	No Yes A learning disability A mental health problem A physical disability A sensory disability Any other special need.
How would you like to be involved?	Consider standing for election as governor Online surveys Take an interest in led consultation / Focus Groups Attend meetings or events
Service preferences?	Medicine eg rehab Accident and Emergency Women's health eg maternity, gynae Children's services Surgery Outpatient Support services eg cleaning, food, parking, volunteers Other support services (please list in ‘Notes’ section) Medicine e.g.Medicine for the elderley Rehabilitation Volunteers Orthopaedics
How are you connected with the Trust?	Other Live within catchment area (public constituency) Someone who uses our services Carer of someone who uses our services Volunteer Member of staff Representing a group/organisation Patient or Carer that lives outside our catchment area.
How did you hear about the trust?	Online Application Public meetings Other (please list in 'Notes') On the trust website Face to face recruitment Received a leaflet eg sent with hospital appointment letter Via our services/staff Through the local press/media

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
Twitter
Ethnic Origin
Religion/Belief
Sexual Orientation
Special Postal Req
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?
How are you connected with the Trust?
How did you hear about the trust?

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