Personal Information – Information About Carer First Name
Preferred Name
Surname
Date of Birth
Gender (Please select) Male Female Non-binary Transgender Other
Gender (Other)
Ethnicity (Please select) White Mixed or Multiple ethnic groups Asian, Asian Scottish or Asian British African, Caribbean or Black Other Ethnic Background Prefer not to say
Home Address
Postcode
Social Locality (Local Health/GP centre)
Home Telephone Number
Work Telephone Number
Mobile Telephone Number
Email Address
Type of care given: (help with personal care, help with shopping, domestic tasks, etc)
For how long have you been providing care for this person? (Please select) Less than one year One year but less than five years Five years but less than ten years Ten years but less than 20 years 20 years or more
How many hours a day do you provide care?
On average, how many hours a week do you spend caring or providing support? (Please select) Up to four hours five to 19 hours 20 – 34 hours 35 – 49 hours 50+ hours
Anything else you want to tell us in relation to this?
Is your caring role impacting on you? (Please select) None Some Lots
If you indicated some or lots above, please detail how you consider your caring role has impacted on you. Please choose all that apply.
Impact (Other)
Do you have other family members who also provide support and care for the person you care for?
If you are not currently registered with Shetland Carers, please provide details of someone who can confirm your caring role e.g. family member / health professional / social worker
Name
Tel No
Relationship to you
Information About Person Being Cared For This section relates to the CARED FOR PERSON. Please choose the correct statement which applies:
Please provide the following information about the CARED FOR PERSON:
**As a minimum, we require the NAME of the cared for person**
Does the cared for person live with you? (Please select) Yes No
First Name
Surname
Gender (Please select) Male Female Non-binary Transgender Other
Gender (Other)
Ethnicity (Please select) White Mixed or Multiple ethnic groups Asian, Asian Scottish or Asian British African, Caribbean or Black Other Ethnic Background Prefer not to say
What is the illness/condition/disability of the person you care for? Please choose all that apply.
Illness/condition/disability (Other)
What is your relationship to the person you provide care for? (Please select) I am the child/grandchild of the cared for person I am the parent/grandparent of the cared for person I am the spouse/partner of the cared for person I am a relative (any other relationship) of the cared for person I am a friend/neighbour of the cared for person
Do you yourself experience any health or wellbeing issues?
Do you experience social isolation?
Can you please let us know where you heard about Shetland Carers?
Other (please detail)
Data Protection Shetland Carers have a legal requirement to submit a Carers Census Return to Scottish Government on an annual basis. All data provided is anonymised. The information which we request in this form is in line with this.
Here at Shetland Carers/Voluntary Action Shetland (VAS) we take your privacy seriously and will only use your personal information to administer your account through our database, to provide the products and services you have requested from us and from time to time to share information relating to the service we provide. In order to provide carers with a better service we are now working in partnership with Shetland Care Attendant Scheme (SCAS) where we will share your information with this organisation via a joint database. If you have any concerns about this please discuss this with us.
Where appropriate, and with your consent, we will liaise with a range of other partners to support you in your caring role.
Please indicate your preferred method(s) of communication:
Throughout the year we would like to send you our quarterly newsletter to provide information relating to our service. Please tick if you agree to us providing you with a copy of our newsletter. You can unsubscribe from receiving our newsletter at any time.
Shetland Carers aligns with the Shetland Child and Adult Protection Procedures and we may need to pass on information where it is deemed necessary to do so.
I HAVE READ THE INFORMATION ABOVE AND I CAN CONFIRM THE DETAILS ARE CORRECT.
I AM EITHER:OR OR OR
Agree & Send
