WAMES Survey of Services for people with ME, CFS, PVFS and carers in Wales 2012

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Thank you for agreeing to take time to complete this questionnaire. No individual will be identified and WAMES will not pass any information on to third parties.

We ask people to complete the online form by 30th July 2012 to have your experiences included in the initial report. We are however happy to accept to completed forms after that date.

Unfortunately you cannot save your answers but you can take rest breaks and return if you leave the questionnaire open and your computer turned one. The questionnaire has to be completed in one sitting. Please take your time and pace yourself!

You can go 'BACK' at any time and check your answers.

1. ABOUT YOU

a) Full Name

(Please give us your preferred contact details in case we need to contact you or you wish us to send you information)

Address

Telephone Number

inc area code

Email address

Please state nearest town

b) Gender *

Male

Female

Prefer not to say

c) Please select as many choices as you wish but don't forget to fill in your contact details above

I am willing to be approached for more information

I would like more information about WAMES

Put me on the mailing list for the WAMES newsletter: ME in Wales

I would like to join the Young People's Group for ages 0-25

I would be willing to speak to the media

I would like a copy of the results of this survey

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