Genomics Focus Group Sign up Form
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1.
Name
2.
Email address
3.
Telephone Number
4.
Address
5.
Postcode
6.
I live in
East Midlands
East of England
Other
7.
Gender
Female
Male
Non-binary
Prefer not to say
Prefer to self-describe (please specify):
8.
Age
18-24 years old
25-49 years old
50-64 years old
65-79 years old
80+ years old
Prefer not to say
9.
Please select your ethnicity
Arab
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Any other Asian/Asian British background
Black/Black British: African
Black/Black British: Caribbean
Black/Black British: Any other Black/Black British background
Mixed/multiple ethnic groups: Asian and White
Mixed/multiple ethnic groups: Black African and White
Mixed/multiple ethnic groups: Black Caribbean and White
Mixed/multiple ethnic groups: Any other Mixed/Multiple ethnic group background
White: British/English/Northern Irish/Scottish/Welsh
White: Irish
White: Gypsy, Traveller or Irish Traveller
White: Roma
White: Any other White background
Prefer not to say
Other (please specify):
10.
Lived Experience
Lay population (no lived experience with genomic testing)
Lived experience (rare disease) Patient, loved one or carer
Lived experience (cancer) Patient, survivor, loved one or carer
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