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Healins
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1.
About you
Which best describes you?
Patient or caregiver
Doctor, nurse, midwife or other health worker
Hospital or clinic owner, manager or IT lead
Laboratory or diagnostic centre
Health insurer or HMO
Other
Your name
Phone number
Region
Choose a region
Greater Accra
Ashanti
Western
Western North
Central
Eastern
Volta
Oti
Northern
Savannah
North East
Upper East
Upper West
Bono
Bono East
Ahafo
Town or district
Optional
2.
How you would like to help
Choose one or more
A 30-minute interview
Short surveys
Best way to reach you
Phone call
SMS
WhatsApp
Email
Preferred language
English
Twi
Ga
Ewe
Dagbani
Hausa
Dagaare
Gurene (Frafra)
Kusaal
Mampruli
Gonja
Sisaala
Other
3.
Your thoughts
Optional
What would make your health records easier to manage?
4.
Your consent
I am 18 or older.
I agree that Healins may store the details above, including any health information I gave, to organise this research. I have read the
privacy notice
.
I agree to be contacted about taking part. I can ask to be removed at any time.
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