MAS contact form Welcome to the helpline log portal. Please use this page to summit all helpline calls and call sheets. Any problems please contact Claire or Tracy 01453 768000 Support Log and Contact Form Is there a Call Sheet related to this case?Yes No Call Log RoutePlease select... Educational Forum Friend/Family Health professional Media MN contact letter MN literature Other charity Other professional Public Health letter Social Media Website Other Date of call Time of call Type of MeningitisPlease select... Bacterial (unknown type) E.Coli (Bacterial) Enterovirus (Viral) Fungal Herpes virus (Viral) Hib (Bacterial) Meningococcal meningitis Meningococcal meningitis & Septicaemia Meningococcal Septicaemia Other Pneumococcal/Septicaemia (Bacterial) Pneumococcal (Bacterial) Streptococcal-GBS (Bacterial) T.B. (Bacterial) Unknown Viral (unknown type) InvolvementPlease select... Affected Person Colleague of Affected Family of Affected Friend of Affected Nursery Other School Support Provider University Workplace Date of Contraction Within the last month Within the last 6 months Within the last year Over one year ago Over 5 years ago Over 10 years ago Unknown Enquiry Type After-effects Benefit info Bereavement Disease info Educational concerns Events enquiry General Literature request Hoax or silent call HPU new case reported Other Recovery Risk enquiry S&S concerns Service enquiry Support contact Symptom card order Vaccine enquiry general Vaccine enquiry MenB Vaccine enquiry MenC Vaccine enquiry pneumo Vaccine enquiry travel Vaccine enquiry ACWY vaccine Wrong number Fundraising enquiry Call Outcome Community fundraising Community Support referral Email Literature Events team Follow-up Helpline Other staff member (please state) Seek medical advice Send out literature Service referral Signposted to (please state) Sports prostheses info Support Needs Form sent Verbal information only Written response Signposted to General comments Contact Form Information taken bySusan PepperSusan MilesSophie MossGerardene Cremin Case Name Relationship to caller Age at contraction Case Age/DOB Disease OutcomePlease select... Hospitalised Recovering (outcome unknown) After Effects Recovered Death Unknown After Effects Amputation Amputation-Double Amputation-Fingers Amputation-Quadruple Amputation-Single Amputation-Toes Amputation-Triple Amputation-Unknown Anxiety Balance Problems Behaviour Problems Brain Damage Cerebal Palsy Cochlear Implant Concentration issues Deafness Depression Development Delay Epilepsy Eyesight Difficulties General Tiredness Growth plate problems Headaches Hearing difficulties Joint Soreness/Stiffness Learning Difficulties Memory Loss Mobility problems Mood Swings Organ damage Other Paralysis Personality changes Scarring Shunt Fitted Skin grafts Speech Problems Temper Tantrums Tissue Damage Other After Effects Information / Explanation Risk Signs & Symptoms Vaccine Information After Effects Recovery Information Support services General Disease Information Other Other Information / Explanation Disease experience and main concerns Clients details First Name Last Name Street address Town Postcode Email Home Phone Mobile Phone Clients Contact Preferences Please let us know: what would they like to hear about Meningitis informationHow we support those affected by meningitisHow you can support usI don't want to hear from youMeningitis Information - includes updates about the impact of the disease, vaccine programmes, our campaigns, and media activity How we support those affected - includes our Family Days, Believe & Achieve weekends, Forever Days, invitations to some key events organised by us e.g. Christmas Carol Concerts How you can support us - includes information about donating your time through volunteering or organising fundraising activities, how to get involved by taking part in an event such as Three Peaks Challenge, or our Five Valleys Walk and how you can donate to us through our cash appeals, or by purchasing merchandise e.g. Christmas cards And please let us know: how we can contact themEmailPostTelephoneSMS Need assistance with this form?