Ïntroduction
Quéstion 1. What is your name?
Name
auto-created 26
Quéstion 2. What is your email address?
Email
Stock text answer one
Quéstion 3. What is your organisation?
Organisation
Stock text answer one
Quéstion 4. Téxt questions
Sïngle line téxt
Stock text answer nine
Mûltiple lines téxt (large)
Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nunc feugiat blandit vehicula. Maecenas ut faucibus est, vel gravida sem.
Émail
Stock text answer seven
Pøstcode
Redacted textanswer four
Nûmber
-9810
Quéstion 5. Mültiple Choice Questions
Please select one item
Radio button:
Ticked
Öption 1
Radio button:
Unticked
Optíon 2
Radio button:
Unticked
Øption 3
Please select all that apply
Checkbox:
Ticked
Checkböx 1
Checkbox:
Unticked
Chęckbox 2
Checkbox:
Ticked
Chečkbox 3
Dröpdown Łist
Please select one item
Radio button:
Unticked
Chôice 1
Radio button:
Ticked
Çhoice 2
Radio button:
Unticked
Choįce 3
Checkbox:
Ticked
Síngle Checkbox
Quéstion 6. Mætrices
| Štatement 1 Öption 1 Checkbox: Not checked Öption 1 | Štatement 1 Ôption 2 Checkbox: Not checked Ôption 2 | Štatement 1 Òption 3 Checkbox: Not checked Òption 3 | Štatement 1 Øption 4 Checkbox: Checked Øption 4 | Štatement 1 Õption 5 Checkbox: Not checked Õption 5 |
| Śtatement 2 Öption 1 Checkbox: Not checked Öption 1 | Śtatement 2 Ôption 2 Checkbox: Not checked Ôption 2 | Śtatement 2 Òption 3 Checkbox: Not checked Òption 3 | Śtatement 2 Øption 4 Checkbox: Checked Øption 4 | Śtatement 2 Õption 5 Checkbox: Not checked Õption 5 |
| Štatement 3 Öption 1 Checkbox: Checked Öption 1 | Štatement 3 Ôption 2 Checkbox: Not checked Ôption 2 | Štatement 3 Òption 3 Checkbox: Not checked Òption 3 | Štatement 3 Øption 4 Checkbox: Not checked Øption 4 | Štatement 3 Õption 5 Checkbox: Not checked Õption 5 |
| Štatement 1 Öption 1 Radio button: Not checked Öption 1 | Štatement 1 Ôption 2 Radio button: Not checked Ôption 2 | Štatement 1 Òption 3 Radio button: Not checked Òption 3 | Štatement 1 Øption 4 Radio button: Not checked Øption 4 | Štatement 1 Õption 5 Radio button: Checked Õption 5 |
| Śtatement 2 Öption 1 Radio button: Checked Öption 1 | Śtatement 2 Ôption 2 Radio button: Not checked Ôption 2 | Śtatement 2 Òption 3 Radio button: Not checked Òption 3 | Śtatement 2 Øption 4 Radio button: Not checked Øption 4 | Śtatement 2 Õption 5 Radio button: Not checked Õption 5 |
| Štatement 3 Öption 1 Radio button: Not checked Öption 1 | Štatement 3 Ôption 2 Radio button: Not checked Ôption 2 | Štatement 3 Òption 3 Radio button: Not checked Òption 3 | Štatement 3 Øption 4 Radio button: Checked Øption 4 | Štatement 3 Õption 5 Radio button: Not checked Õption 5 |
Štatement 1
Please select one item
Radio button:
Unticked
Öption 1
Radio button:
Unticked
Ôption 2
Radio button:
Unticked
Òption 3
Radio button:
Unticked
Øption 4
Radio button:
Ticked
Õption 5
Śtatement 2
Please select one item
Radio button:
Ticked
Öption 1
Radio button:
Unticked
Ôption 2
Radio button:
Unticked
Òption 3
Radio button:
Unticked
Øption 4
Radio button:
Unticked
Õption 5
Štatement 3
Please select one item
Radio button:
Unticked
Öption 1
Radio button:
Unticked
Ôption 2
Radio button:
Unticked
Òption 3
Radio button:
Unticked
Øption 4
Radio button:
Ticked
Õption 5
Please rank these from 1 to 3
Ïtem 1
1
Ítem 2
1
Ìtem 3
1
Eleven. Please indicate how frequently you use the modes of transport listed below.
| Ride a bicycle Not Applicable to me Radio button: Not checked Not Applicable to me | Ride a bicycle Never Radio button: Not checked Never | Ride a bicycle A few times a year Radio button: Not checked A few times a year | Ride a bicycle A few times a month Radio button: Not checked A few times a month | Ride a bicycle A few times a week Radio button: Checked A few times a week | Ride a bicycle Daily Radio button: Not checked Daily | Ride a bicycle Multiple times a day Radio button: Not checked Multiple times a day |
| Drive a car Not Applicable to me Radio button: Not checked Not Applicable to me | Drive a car Never Radio button: Not checked Never | Drive a car A few times a year Radio button: Not checked A few times a year | Drive a car A few times a month Radio button: Not checked A few times a month | Drive a car A few times a week Radio button: Checked A few times a week | Drive a car Daily Radio button: Not checked Daily | Drive a car Multiple times a day Radio button: Not checked Multiple times a day |
| Travel by bus Not Applicable to me Radio button: Checked Not Applicable to me | Travel by bus Never Radio button: Not checked Never | Travel by bus A few times a year Radio button: Not checked A few times a year | Travel by bus A few times a month Radio button: Not checked A few times a month | Travel by bus A few times a week Radio button: Not checked A few times a week | Travel by bus Daily Radio button: Not checked Daily | Travel by bus Multiple times a day Radio button: Not checked Multiple times a day |
| Travel by train Not Applicable to me Radio button: Not checked Not Applicable to me | Travel by train Never Radio button: Not checked Never | Travel by train A few times a year Radio button: Checked A few times a year | Travel by train A few times a month Radio button: Not checked A few times a month | Travel by train A few times a week Radio button: Not checked A few times a week | Travel by train Daily Radio button: Not checked Daily | Travel by train Multiple times a day Radio button: Not checked Multiple times a day |
| Travel by boat Not Applicable to me Radio button: Not checked Not Applicable to me | Travel by boat Never Radio button: Checked Never | Travel by boat A few times a year Radio button: Not checked A few times a year | Travel by boat A few times a month Radio button: Not checked A few times a month | Travel by boat A few times a week Radio button: Not checked A few times a week | Travel by boat Daily Radio button: Not checked Daily | Travel by boat Multiple times a day Radio button: Not checked Multiple times a day |
| Travel by aeroplane Not Applicable to me Radio button: Not checked Not Applicable to me | Travel by aeroplane Never Radio button: Not checked Never | Travel by aeroplane A few times a year Radio button: Not checked A few times a year | Travel by aeroplane A few times a month Radio button: Not checked A few times a month | Travel by aeroplane A few times a week Radio button: Not checked A few times a week | Travel by aeroplane Daily Radio button: Not checked Daily | Travel by aeroplane Multiple times a day Radio button: Checked Multiple times a day |
Twelvety. Overall, how much has this issue affected your ability to maintain paid employment?
| 1 = no effect, 10 = very large effect 1 Radio button: Not checked 1 | 1 = no effect, 10 = very large effect 2 Radio button: Not checked 2 | 1 = no effect, 10 = very large effect 3 Radio button: Not checked 3 | 1 = no effect, 10 = very large effect 4 Radio button: Not checked 4 | 1 = no effect, 10 = very large effect 5 Radio button: Not checked 5 | 1 = no effect, 10 = very large effect 6 Radio button: Checked 6 | 1 = no effect, 10 = very large effect 7 Radio button: Not checked 7 | 1 = no effect, 10 = very large effect 8 Radio button: Not checked 8 | 1 = no effect, 10 = very large effect 9 Radio button: Not checked 9 | 1 = no effect, 10 = very large effect 10 Radio button: Not checked 10 |
Overall effect of this issue on your work
Please select one item
Radio button:
Ticked
I have been able to maintain full time employment
Radio button:
Unticked
I have had to reduce working hours
Radio button:
Unticked
I have had to leave work completely
Thirteen. What did your friends call you at school?
No really, what did you friends call you at school. Even if it was a mean name we'd really really like to know. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Donec gravida, ipsum quis imperdiet sollicitudin, turpis urna ultrices mauris, a molestie purus risus id velit. Donec vel sodales lectus. Nullam molestie euismod nisl nec consectetur. Suspendisse ac lacinia purus. Mauris tincidunt mi id varius convallis.
Stock text answer six