IA Support Volunteer - Ileostomy & Internal Pouch Association

Thank you for taking the time to complete this questionnaire; it will be an invaluable resource for One2One Support.

Your responses will enable us to improve our support by matching volunteers to those requesting someone to speak to. To provide this level of support we are requesting some details of a personal nature – please be assured that all the questions relate to enquiries that we receive from our members and that your personal information will be held securely and used only for the purposes of facilitating your participation in IA’s One2One Support. However, if there are any questions that you prefer not to answer, please tick the ‘prefer not to say’ box or leave them blank.

At the end of this questionnaire you will find a Submit button, which will send your details directly to IA.

"*" indicates required fields

Step 1 of 8

12%

Do you wish to continue in your role as an IA Support Volunteer?

Yes

Consent*

Please tick the box to provide your consent for IA to hold your details and contact you directly in relation to One2One Support

Name of local Member Organisation:*

Title*

First Name*

Surname*

Address Line 1*

Address Line 2*

Postcode*

Home telephone number*

Mobile

Email address*

Year of Birth*

Occupation*

If retired, please state your former occupation

Which of the following best describes your marital status?*

Prefer not to say

Married

Living with partner

Single

Other

If Other, please use this space to provide any further details you are comfortable sharing:

If you have children, were they born pre- or post-surgery?*

Prefer not to say

Pre-surgery

Post-surgery

How old are your children?*

Regarding your sexuality, which of the following best represents how you think of yourself?*

Prefer not to say

Heterosexual

Gay/Lesbian

Bisexual

Other

If Other, please use this space to provide any further details you are comfortable sharing:

Do you identify with a religion?*

Prefer not to say

Yes

If yes, and you are happy to share further information please provide details of the religion to which you most identify. For example, Islam, Buddhism, Christianity, Hinduism, Sikhism

Which of the following best describes your ethnicity?*

Prefer not to say

White

Asian

Black/African/Caribbean

Mixed ethnicitty

Other

Please use the space below if you would like to expand your answer and provide further details relating to your ethnicity such as Asian Indian, Asian Bangladeshi, or mixed white and black African.

Making Contact

What is your preferred method of contact ?

Text

Telephone (landline)

Mobile phone

When is your preferred time of contact?*

Medical/Dietary Background

Type of Operation*

Date of Operation*

MM slash DD slash YYYY

Reason for Surgery*

Other surgery notes you feel might be relevant

Have you had, or do you have any specific medical issues relating to your ileostomy or internal pouch? E.g., Hernia/Fistula/High output/Skin irritation/Prolapsed stoma:*

Prefer not to say

Yes

If yes, please provide further details

Do you have any specific dietary needs e.g., Vegetarian/Vegan/Coeliac Disease?*

Prefer not to say

Yes

If yes, please provide further details

Do you consider yourself disabled?*

Prefer not to say

Yes

If yes, please provide further details:

Hobbies/interests

Do you play any sports or are you involved in any activities which may be relevant when matching a patient with a support volunteer?*

Yes

If yes, please provide details

IA Training

Have you undertaken any IA training?*

Yes

If yes, please tick the appropriate box:

One day course

Qualified course

Please provide the year/approximate year of training*

If you have completed a course, would it be helpful to receive a refresher course?

Yes

If you have not received any IA training, would you be prepared to complete a course?

Yes

Please provide any information you feel would be relevant, or any ideas that you may have regarding training:

Other Comments

We are sorry to lose you as a valued Support Volunteer but appreciate everything you have done to help other ostomates over the time you have been a Volunteer with us. We hope you may be able to rejoin our team of Volunteers again at some point in the future. Thank you for your time and commitment. Your details will be removed from the database.

Title*

First Name*

Surname*

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