Keeping Control research study: Recruitment Monitoring Form

This research is exploring what people with mental health problems think and feel about abuse and staying safe from harm. We are interested in talking to people who have been abused or victimized because of their mental health problems. We want to learn from you so that the process of 'adult safeguarding' will work better for people with mental health problems and support them to stay safe.

We are planning to interview 30 people with a range of different backgrounds and experiences who live across England. Each interview participant will receive a £10 voucher as a token of thanks.

We would like to know more about you in order to ensure that we are reaching a range of different people with our research. The information you give on this form will remain strictly confidentialbut it will help us to monitor and plan our research interviews. You should hear from us by the end of June 2016 at the latest.

Please be assured that, if you are not interviewed, it is nothing personal about you or your experiences. It is simply that we need to interview a range of different people and your characteristics may cause you to fall outside of the range of people we need to speak to.

We fully appreciate that it is difficult to come forward about sensitive issues like this. Many thanks for being willing to share your experiences.

If you are thinking of reporting an incident or seeking support now, there are some helpful organisations and contacts on the last page of this form. There is also more information about ‘adult safeguarding’.

Please return your form to or post to the research lead:

DrSarah Carr, Department of Mental Health, Social Work and Integrative Medicine, The Burroughs, Hendon, LONDON NW4 4BT.

If you need any advice onfilling in the form or have any other queries youcan email us at: or telephone Alison Faulkner on: 07729301379.

Please give your contact details below:

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About you

Please mark the following questions witha cross beside the answer that applies to you.

  1. Your age (please put a cross by the answer that applies)

18-25 26-35 36-45 46-55 56-65 66-75 over 75

  1. How do you describe your gender?

a) At birth were you described as (please put a cross by the answer that applies)

Female

Male

Intersex

Prefer not to say

b) Which of the following describes how you identify now (please put a cross by the answer that applies)

Female

Male

Prefer not to say

In another way (please describe below)

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  1. Please tell us your ethnicity (Please put a cross by the relevant answer or describe in words)

White / Black/Black British
British / African
Irish / African Caribbean
European
Other……………………………… / Black British
Other…………………………………….
Asian/Asian British / Mixed heritage
Bangladeshi / White and African
Indian / White and African Caribbean
Pakistani / White and Asian
Other………………………………………. / Other……………………………………….
Chinese / Gypsy/traveller
British Chinese
Chinese
Other…………………………………….. / Gypsy
Irish Traveller
Romany
Other ethnic background (please describe below)
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  1. How would you describe your sexual orientation?

Heterosexual Gay/lesbian Bisexual

Don't know/not sure Other Prefer not to say

  1. Do you consider yourself to have a disability?

(The Equality Act 2010 says a disability is a “physical or mental impairment which has a substantial and adverse affect on someone’s ability to carry out normal day to day activities”). Please put a cross by the answer that appliesto you

Yes No

Please describe your disability or disabilities:

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  1. Your experience of mental distress or mental health problems

How long have you used - or been in contact with - mental health services? (please write below)
Please describe your mental distress/ health difficulties in your own words below:
  1. Your experience of abuse, harassment, 'hate crime'

Please give a brief description of the type of abuse you have experienced below:
I have reported hate crime to the police or social services or other agency
(if yes, please put a cross in the box)
  1. Can you describe where you live? (please put a cross next to the answer that applies to you)

Rural

Urban (City)

Small Town

MixedUrban/Rural

  1. We have a team of three interviewers, all of whom have used mental health services themselves. All the interviewers are women. One is Black British and two are White British. One of the interviewers identifies as gay and one as bisexual. Let us know if you have a preference about who you speak to.

While we cannot match you exactly with someone, we want you to be as comfortable as possible. If you would prefer to speak to a White British man or to a South Asian woman, we may be able to arrange this.

Please state your preference below if you have one:

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  1. We can conduct the interview face to face, via the telephone or on Skype.

Please state your preference below if you have one:

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Many thanks again.

We very much appreciate your interest in the research project.
About Adult Safeguarding

Everyone has a right to live a life that is free from abuse and neglect. Safeguarding is about protecting adults at risk from abuse or neglect. It means making sure people are supported to stay safe,to make the most of their lives and get their full equal rights.

The Care Act 2014 introduced new safeguarding duties for local authorities including:

  • leading a multi-agency local adult safeguarding system;
  • making or causing enquiries to be made where there is a safeguarding concern;
  • hosting safeguarding adults boards;
  • carrying out safeguarding adults reviews; and arranging for the provision of independent advocates.

This means that there is a local safeguarding adults contactbased in your local authority, designed to act on your behalf should you, or anyone you know, be at risk of abuse or neglect. The contact details should be on your local authority website.

Abuse is an action or a lack of action that causes harm to a person. Abuse can be an accident or it can be done on purpose. Abuse can be a crime, but it is not always. Abuse can be:

  • Physical
  • Sexual
  • Emotional/psychological
  • Financial
  • Discriminatory
  • Neglect

It can occur in your home, in the community, within health or social care services and between friends. If you think that you have experienced any abuse of this nature, you can contact the police or your local safeguarding adults team. You could also talk to your GP or social worker if you are in touch with services.If you do not feel able to do this, speak to a friend or someone you trust about what has happened to you. They may be able to help you to report the abuse.

Some helpful numbers if you have experienced or are experiencing abuse or victimisation

Victim Support: 08 08 16 89 111

Action on Elder Abuse0808 808 8141

The Samaritans: 08457 90 90 90

National Centre for Domestic Violence: 0800 970 2070