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Research engagement form

Research Champion Role

Note: Questions marked by * are mandatory

*This is a mandatory field. Your name

*This is a mandatory field. Contact email address

*This is a mandatory field. Contact telephone number

*This is a mandatory field. What age group do you belong to?

16-20
21-30
31-40
41-50
51-60
61-64
65 & over
Rather not say

*This is a mandatory field. What is your ethnic group?

White British
White Irish
White Other
Black Caribbean
Black African
Black Other
Indian
Pakistani
Bangladeshi
Asian Other
White & Black Caribbean
White & Black African
White & Asian
Mixed Other
Chinese
Any Other

*This is a mandatory field. What is your main language?

Bulgarian
English
Hungarian
Latvian
Lithuanian
Polish
Portuguese
Romanian
Russian
Spanish
Other (please specify)

*This is a mandatory field. Are your day-to-day activities limited because of a health problem or disability which has lasted, or expected to last, at least 12 months (including any problems related to old age)?

No
Prefer not to say
Yes, the health problem/disability limits me a little
Yes, the health problem/disability limits me a lot

If you answered 'yes' to the previous question, please indicate you disability - people may experience more than one type of impairment, in which case you may indicate more than one

Mobility
Visual impairment
Hearing impairment
Social or behavioural issues
Learning difficulties
Long standing illness
Prefer not to say
Other

In relation to the previous question do you have any specific needs or requirements?

Yes
No

*This is a mandatory field. What is your gender?

Male
Female
Other
Rather not say

*This is a mandatory field. Gender reassignment: Have you gone through any part of a process, or do you intend (including thoughts or actions) to bring your physical sex appearance, and/or your gender role, more in line with your gender identity? (This could include changing your name, your appearance and the way you dress, taking hormones or having gender confirming surgery)

Yes
No
Rather not say

*This is a mandatory field. What is your religion/belief?

Buddist
Catholicism
Christian
Hindu
Jain
Jewish
Muslim
Sikh
No Religion
Prefer not to say
Other

*This is a mandatory field. Which of the following options best describes your sexual orientation?

Please Choose
Bi-sexual
Gay
Heterosexual
Lesbian
Rather not say

Email:

Comment:

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