1. About You2. About the Person3. Your Complaint4. What Happened5. More Info Information about you Tell us a little about yourself. My personal details Title * Mr Ms Miss Mrs Mx Dr Other Other (Title) First Name * Gender * Male Female I don't want to answer I don't know Other Last Name * Other (Gender) 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 don't want to answer I don't know my age Which ethnic group do you belong to * NZ European Māori Samoan Cook Island Māori Tongan Niuean Chinese Indian I don’t know my ethnicity I do not 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 Other difficulty - please specify 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 Other accessibility needs - please specify What is your relationship to the person/organisation being complained about? * Specifically, are you a current or former: Patient Employer Employee Volunteer Contractor Tangata whaiora/service user Professional colleague Other Other relationship - Please specify * My contact details Email Phone Number What is the best way to contact you? * Phone Email Post Relay Service Other Other contact method Address * Suburb City Postcode
