Guide Dogs Research

Please click to select ethnic backgroundWhite/White BritishBlack/Black British (Caribbean, African, other Black background)White Eastern European originAsian/Asian British (Pakistani, Bangladeshi, Indian)Other (Please specify)

Which of the following statements apply to you?
Choose all that apply

I have a visual impairment and have received a certificate of visual impairment (CVI) - or a BP1 certificate (in Scotland prior to April 2018)I am closely related to, or a very close friend of, a person aged over 18 years with sight loss and am involved in supporting them on a regular basisI am closely related to a person aged under 18 years with sight loss and am involved in supporting them on a regular basisNone of the above
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ADULTS WITH SIGHT LOSS
When were you first diagnosed with sight loss?

Are you personally registered as "severely sight impaired/blind" or as "sight impaired/partially sighted"? Or are you not currently registered as either?

I am registered as severely sight impaired/blindI am registered as sight impaired/partially sightedI am not registered as severely sight impaired or sight impaired, but I have a certificate of visual impairment (CVI) - or a BP1 certificate (in Scotland prior to 2018)None of the above

Could you tell us a little more about your sight condition?
Which sight condition have you been diagnosed with by a medical professional?
Choose all that apply

Retinitis pigmentosaGlaucomaMacular degeneration (or Age-related macular degeneration or AMD)Diabetic retinopathy (or other diabetic eye disease)KeratoconusCataractAnother diagnosed sight condition (Please specify)n/a

Which of the following statements would be true of you personally?
Choose all that apply

I have made visits to and/or had treatment from an eye specialist at a hospital (Note: this doesn't include a GP or an optician)I have experienced a significant deterioration in sight which has affected my ability to carry out tasks on a daily basisAs far as I know my sight condition cannot be corrected by glasses or surgery (to within 90% of my previous eyesight)n/a

Which of the following statements apply to you personally?

I am currently a guide dog ownerI have been a guide dog owner in the pastI use another service provided by the charity Guide DogsI have in the past used another service provided by the charity Guide DogsNone of the above

In addition to your sight condition, do you have any disabilities or long-term conditions which are described as "additional needs". If so, what are they (for example a hearing impairment, arthritis or another physical disability)?

Yes – I have additional needsNo – I have no additional needsn/a

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FRIENDS/FAMILY OF ADULT WITH SIGHT LOSS AND FAMILY OF YOUNG PERSON WITH SIGHT LOSS

What is their age?

Which of the following statements would be true of you personally in terms of your relationship with this person?
Choose all that apply

I have accompanied them to a medical appointmentI have recommended or suggested potential services or support that might be available to themI see them at least once a week in a normal weekI am actively involved in supporting themI was actively involved in supporting them during the time immediately following the diagnosis of their sight condition (or during the time when their eyesight deteriorated to the point where they needed support, if this is significantly different from time of diagnosis)n/a

When were they first diagnosed with sight loss?

Could you tell us a little more about their sight condition?
Firstly, which of the following would apply to them?

They are registered as severely sight impaired/ blindThey are registered as sight impaired/ partially sightedThey are not registered as severely sight impaired or sight impaired, but they have a certificate of visual impairment (CVI) - or a BP1 certificate (in Scotland prior to April 2018)None of the aboveDon't know

Which sight condition have they been diagnosed with?

Choose all that apply

Retinitis pigmentosaGlaucomaMacular degeneration (or Age-related macular degeneration or AMD)Diabetic retinopathy (or other diabetic eye disease)KeratoconusCataractAnother diagnosed sight condition (Please specify)n/a

Which of the following statements apply to the person with the sight loss?

I am currently a guide dog ownerI have been a guide dog owner in the pastI use another service provided by the charity Guide DogsI have in the past used another service provided by the charity Guide DogsNone of the above

In addition to their sight condition, do they have any disabilities or long-term conditions which are described as "additional needs". If so, what are they (for example a hearing impairment, arthritis or another physical disability)?

Yes – they have additional needsNo – they have no additional needsn/a

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ADULT WITH SIGHT LOSS ONLY
Who else lives in your household with you?

It's just meMy partnerMy partner and one or more childrenAnother situation (please specify)n/a

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Which group or groups are you interested in attending?

If, for example, you're accompanying the sight impaired participant as well as taking part in a family/friends group yourself, you can select both groups (Group 1 and Group 3, for example).

Group 1: Adults with sight loss - 2.00pmGroup 2: Adults with sight loss - 6.30pmGroup 3: Family & friends of adults with sight loss - 2.00pmGroup 4: Family & friends of adults with sight loss - 6.30pmGroup 5: Family of children and young people with sight loss - 11.30amGroup 6: Family of children and young people with sight loss - 4.15pmGroup 7: Young people aged 14 to 18 with sight loss - 4.15pm

Name of sight impaired relative.