Are you... Inpatient Outpatient Visitor Staff What ward/dept did you attend? How would you describe the treatment/care the patient received today? (what was good? What was poor? What could be improved?) How does your care at Oldham Hospital compare to your experience at other hospitals? Did you find the hospital to be welcoming, clean and well-maintained? Please explain Any other comments Which of the following options best describe how you think of yourself? Man (including trans man) Woman (including trans woman) Non-binary Other… You can use this space to describe your gender in your own terms. Is your gender identity the same as it was at birth? Yes No Your age group 0-12 13-15 16-17 18-24 25-49 50-64 65-79 80+ Prefer not to say Not known Ethnicity Ethnicity - None -ArabAsian / Asian British: BangladeshiAsian / Asian British: ChineseAsian / Asian British: IndianAsian / Asian British: PakistaniAsian / Asian British: Any other Asian / Asian British BackgroundBlack / Black British: AfricanBlack / Black British: CaribbeanBlack / Black British: Any other Black / Black British BackgroundMixed / Multiple ethnic groups: Asian and WhiteMixed / Multiple ethnic groups: Black African and WhiteMixed / Multiple ethnic groups: Black Caribbean and WhiteMixed / Multiple ethnic groups: Any other Mixed / Multiple ethnic groups backgroundWhite: British / English / Northern Irish / Scottish / WelshWhite: IrishWhite: Gypsy / Traveller / Irish Traveler White: RomaWhite: Any other White backgroundPrefer not to sayNot knownOther ethnic group… Please use this space to describe your ethnicity Sexual Orientation Heterosexual / Straight Gay Man Gay Woman / Lesbian Bisexual Asexual Prefer not to answer Prefer to self descibe Please use this space to describe your sexual orientation Do you have a disability? Yes No Prefer not to say Not known Town or area you live in Town or area you live in - None -ChaddertonColdhurstDelphDenshawDiggleDobcrossFailsworthGlodwickGrasscroftGreenfieldHathershawHollinwoodLeesMoorsideOldhamRoytonSaddleworthSpringheadShaw and CromptonWaterheadWestwoodOther… Please state your Town or area Submit Leave this field blank
