H.2429-0823 Vision Impairment Quality of Life Survey

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What is your first name?

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What is your surname?

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Please tell us your age.

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Your answer must be between 0 and 99

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What is your contact number?

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Where in the UK are you based?

Choose one of the following answers

Northwest
Northeast
Yorkshire and Humber
East Midlands
West Midlands
East of England
Southeast
Southwest
London and Surrounds
Wales
Scotland
Northern Ireland

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Please tell us your email address?

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What is your postcode?

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Are you...

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Male
Female

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Do you personally have a vision impairment that is not correctable by glasses?

Choose one of the following answers

Yes
No

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As far as you know, are you registered as severely sight impaired or sight impaired?

Choose one of the following answers

Registered severely sight impaired
Registered partially sight impaired
Registered but don’t know which category
Not registered
I’m not sure

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How would you define the severity of your vision impairment?

Choose one of the following answers

Mild
Moderate
Severe
Blind

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Have you ever received support or services from any of the following organisations, in relation to your vision impairment?

Check all that apply

Guide Dogs
RNIB
Thomas Pocklington Trust
Blind Veterans UK
Glaucoma UK
Henshaws
Macular Society
Retina UK
SeeAbility
Sense
Local vision impairment charities that operates where you live
I do not receive support from any organisations
Other:

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This session will be taking place as an online survey and will take roughly 15 minutes to complete. As a thank you for your time you will receive £10 paid via bank transfer. If you are selected for this session you will be notified via email. Please can you confirm you are happy with this information?

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