I am a survivor of sepsisSomeone close to me (e.g.family member, partner or friend) has experienced sepsisOther

Speaking at in-person eventsSpeaking at online events (Zoom or Teams)Talking to the media (e.g. press, radio, TV)Sharing in writing (e.g. blog or article)Sharing through social mediaIn a short videoI’m not sure yet – I’d like to learn more first

YesNoMaybe - I'd need support or ideas

I understand this is a voluntary role. It is unpaid, but agreed, reasonable expenses will be reimbursed by the UK Sepsis Trust.

I understand that I will only be asked to share my experience in ways I’m comfortable with, and can say no at any time.

I understand that if I progress in this role, I may be asked to provide proof of ID and contact details for a reference.

I understand that some opportunities (e.g. school visits or public-facing events) may require a DBS check, and the UK Sepsis Trust will support me through that process if needed.

The UK Sepsis Trust website Social media Word of mouth Volunteer platform (e.g. Do-it, Reach) Another organisation or groupOther

Asian, Asian British or Asian WelshBlack, Black British, Black Welsh, Caribbean or African Mixed or Multiple ethnic groupsWhite: English, Welsh, Scottish, Northern Irish or BritishWhite: IrishWhite: Gypsy or Irish Traveller, Roma or Other WhiteOther ethnic groupPrefer not to say

YesNoPrefer not to say

Modern professional and traditional professional occupations such as: teacher, nurse, physiotherapist, social worker, musician, police officer (sergeant or above), software designer, accountant, solicitor, medical practitioner, scientist, civil or mechanical engineer. Senior, middle or junior managers or administrators such as: finance manager, chief executive, large business owner, office manager, retail manager, bank manager, restaurant manager, warehouse manager.Clerical and intermediate occupations such as: secretary, personal assistant, call centre agent, clerical worker, nursery nurse. Technical and craft occupations such as: motor mechanic, plumber, printer, electrician, gardener, train driver. Routine, semi-routine manual and service occupations such as: postal worker, machine operative, security guard, caretaker, farm worker, catering assistant, sales assistant, HGV driver, cleaner, porter, packer, labourer, waiter or waitress, bar staff. Long-term unemployed (claimed Jobseeker’s Allowance or earlier unemployment benefit for more than a year)Small business owners who employed less than 25 people such as: corner shop owners, small plumbing companies, retail shop owner, single restaurant or cafe owner, taxi owner, garage owner Other such as: retired, this question does not apply to me, I don’t know.I prefer not to say

I consent to the UK Sepsis Trust storing and using my data for volunteering purposes.

I confirm that the information I have provided is accurate.

I understand I may be contacted by email with next steps and further information.

Page 1

Page 2

Page 3

Page 4