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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)
How would you like to be involved?	Consider standing for election as governor I'm happy to be contacted about meetings and surveys Exclude from Postal Newsletter
Service preferences	Medicine Cancer Services Other support services (please list in ‘Notes’ section) Antenatal/Maternity Cardiology Infection Control Dermatology Ear, Nose & Throat Emergency Department Gynaecology Opthalmology Orthodontics Orthopaedic Paediatrics Surgery Trauma
How are you connected with the Trust?	I am a member of a community organisation I am a relative of a member of staff I am a relative of a patient I am a carer of a patient Other (Please Specify) I've been a patient at the RD&E Stakeholder
How did you hear about the trust?	Direct Mail Newspaper From another member At the Hospital RDEFT Website Governor Recruitment Session Recruit a Friend RDEFT Membership Stand

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