REF:

New Deal for Carers – Registration of Interest Questionnaire

If you would like to take part in the event nearest to you, we need you to fill in this questionnaire. This will help us to make sure we get the right mix of carers on the day. It’s very short and should only take you a few minutes to complete. The details you give us are confidential and we will not share them with anyone else.

We also need you to fill in your contact details so we can get back in touch with you if you are selected to take part.

As you will see most questions ask you to tick a box like this:

Some ask you to write in words like this: Pleasewrite in:

We will only be selecting 50 people to take part to take part in each event. So it’s really important you return the questionnaire, along with your contact details, in the prepaid envelope provided within the next week.

We’ll use the information we receive from everyone to select a mix of different types of carers. If you are selected, we will telephone you to let you know a bit more about what will happen at the event and to let you know the location.

I do hope you will be able to spare the time to take part in this stage of this important exercise. I hope to meet you at the event.

Yours sincerely,

Rebecca Morris
Research Director, Opinion Leader

REF:

PLEASE ANSWER ALL THE FOLLOWING QUESTIONS.

1.Please tick the option below which best describes you. (ONE TICK ONLY)

I am a carerand work for a professional carer organisation
I am a carerand DO NOT work for a professional carer organisation
I am not a carer

2.Which event are you interested in taking part in? (PLEASE TICK ONE BOX ONLY)

Nottingham–17thSeptember / 1 / London - 5thOctober / 6
Guildford–21stSeptember / 2 / Newcastle–10thOctober / 7
Birmingham–25thSeptember / 3 / Leeds–12thOctober / 8
Exeter–27thSeptember / 4 / Manchester–15thOctober / 9
Norwich - 3rdOctober / 5 / London (150 person event) –5th November / 10
Leeds (150 person event) –9th November / 11

3.What is your gender? (PLEASE TICK ONE BOX ONLY)

Male / 1
Female / 2

4.What was your age last birthday? (PLEASE TICK ONE BOX ONLY)

Under 18 / 1 / 45-54 / 4
18-34 / 2 / 55-65 / 5
34-44 / 3 / 65+ / 6

5.Which of the following best describes your ethnic background? (PLEASE TICK ONE BOX ONLY)

White British / Indian
White Irish / Pakistani
Any other white background / Bangladeshi
Mixed - White and Black Caribbean / Any other Asian Background
Mixed - White and Black African / Caribbean
Mixed - White and Asian / African
Any other mixed background / Any other Black background
Chinese
Any other (please write in below)

6.What is your working status? (PLEASE TICK ONE BOX ONLY)

Working full-time / Full-time student/school
Working part-time / Looking after home/family
Retired / Permanently sick or disabled
Unemployed / Full time carer
Other

7.If you work, describe your job, giving details of your level of responsibility. Please write in:

8.If retired or unemployed for less than 6 months, please describe your previous job. Please write in:

9.Are you the Chief Income Earner for your household? (PLEASE TICK ONE BOX ONLY)

Yes / No

10.If no, please state the occupation of the Chief Income Earner. Please write in:

11.Which of the following best describes the person you look after, or givehelp or support to?: (PLEASE TICK ONE BOX ONLY)

  • An adult with a physical disability

  • An adult with a sensory impairment

  • An adult with a mental illness

  • An adult dealing with substance misuse

  • An adult with learning disabilities

  • A child with a disability (of any kind) - I am the parent of that child

  • A child with a disability (of any kind) - I am not the parent of that child

  • Other (please write in below)

12.And how many hours a week do you look after, or give help or support, to this person?: (PLEASE TICK ONE BOX ONLY)

1-19 hours a week
20-49 hours a week
50+ hours a week

13.How would you describe the area where you live?

Urban (City, built up area)
Suburban (small town, outskirts of a city)
Rural (countryside, not built area)

14.If you are happy for Opinion Leader to contact you from time to time about other research please tick this box

/

15.

Contact details

Please fill in your contact details below if you would like to take part in one of the events. If you are selected, we’ll need to call you back to tell you more about the day and send you further information about the event.

In BLOCK CAPITALS PLEASE

NAME:
ADDRESS:
POSTCODE:
TEL NO: / Daytime:______
Evening:______
Mobile: ______
EMAIL:

To ensure your confidentiality, we promise:

To store your contact details separately from any other information you give us

To store your contact details securely

We also guarantee you that we won’t pass your details onto anyone else.

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE. PLEASE PUT IT IN AN ENVELOPE AND SEND TO:

FREEPOST RLUX-ABGU-EBTX

FQ LLP FieldWorks

London

SE1 2YE

(WE’VE PAID THE POSTAGE, SO YOU DON’T NEED A STAMP)

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