1. About You2. Your Complaint3. What Happened4. More Info Tell us a little about yourself My personal details Title * Mr Ms Miss Mrs Mx Dr Other Other (Title) Gender * Male Female I do not wish to answer I don't know Other Other (Gender) First Name * Last Name * Date of Birth * Age Group * Under 15 15-17 years 18-24 years 25-34 years 35-49 years 50-64 years 65-74 years 75-84 years 85+ years I do not want to answer I don't know my age Which ethnic group do you belong to * Please select all that apply. NZ European Māori Samoan Cook Island Māori Tongan Niuean Chinese Indian I don’t know I don't want to answer Other (Please Specify) Other, eg, Dutch, Japanese, Tokelauan * Do you identify as having a disability? * Yes No I don't want to answer Do you have difficulty with any of the following? * Please select all that apply. Seeing, even if wearing glasses Hearing, even if using a hearing aid Walking or climbing steps Remembering or concentrating Self-care (eg, personal hygiene) Understanding or being understood by others, even when the conversation is in your usual language I don’t have difficulty with any of those things I don’t want to answer this question Other difficulty — Please specify Other difficulty * Do you have any accessibility needs? * For example: “I prefer documents in large print”; “Please talk loudly and clearly as I have a hearing impairment”. Yes No Please specify Do you know your NHI number? * The National Health Index number is a unique identifier given to every person who uses health and disability services in New Zealand. Yes No NHI Number My contact details Email Phone Number What is the best way to contact you? * Phone Email Post Relay Service Other Other way - please specify Address * Suburb City Postcode
