Application form

Tell us a little about yourself

Name:

/ Mrs/Mr/Ms/Miss
Address: / Postcode:
Telephone: / Home: / Mobile:
Email address:
GP Practice / D.o.B:
Do you have support needs to be able to attend meetings? (ie an interpreter)
No / Yes
If yes, please provide details:
Have you been or are you involved in any service user groups?
No / Yes
If yes, please provide details:
Please provide a brief summary of any relevant skills and experience you could bring to our group (continue on a separate sheet if necessary – max 400 words)
Declaration of Interest
Please use this section to declare any interests you may have which are relevant to the Leeds West CCG Assurance Group(Any interests declared will not necessarily impact on your ability to participate in the group.
“Interests” include, but are not limited to:
  • Directorships/Non-Executive Directors in private companies/PLC providing or potentially providing services to or commissioning with the NHS
  • Ownership, part ownership of companies/consultancies likely to do business with the NHS
  • Shareholdings in businesses likely to do business with the NHS
  • A position of trust in a charity/voluntary organisation in health or social care
  • A position on a forum or group either within or external to the NHS
  • Any organisation or commercial interest contracting for NHS services
Please detail any relevant interests (please feel free to continue on a separate sheet):

Please sign and date to confirm all of the above details are correct.

Signature……………………….

Date…………………………….

Equality Monitoring

This section of the form is optional, however, this information will help to ensure that the Patient Assurance Group is representative of the population of Leeds and help us identify areas we need to carry out more promotion.

Disabled

Date of Birth: / Gender: Male Female
How would you define your ethnic origin?
Please tick the appropriate box to indicate your ethnic background. If you fit into the any other category, please indicate in the appropriate box.
White
British
Irish
Any other White background (please specify): …………………………… / Dual Ethnicity
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background (please specify): ……………………………
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background (please specify):…………………………… / Black or Black British
Caribbean
African
Any other Black background please specify: ……………………………
Other ethnic groups
Chinese
Gypsy/Traveller
Any other background please specify: ……………………………
Do you consider yourself to be disabled? Yes No
If yes, please indicate nature of disability
Physical impairment, (such as using a wheelchair to get around and / or difficulty using their arms) / Sensory impairment, (such as being blind / having a serious visual impairment or being deaf / having a serious hearing impairment)
Mental health condition, (such as depression or schizophrenia) / Learning disability, (such as Downs syndrome or dyslexia) or cognitive impairment (such as autism or head-injury)
Long-standing illness or health condition (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy)
Sexual Orientation: / Relationship Status
Heterosexual/ Straight
Bisexual / Gay man
Lesbian/Gay woman / Married
Civil Partnership
Cohabiting / Single
Other
Please tick the appropriate box to describe your religion or belief:
Christian
Hindu
Jewish / Muslim
Buddhist
Sikh / No Religion
Other (please specify)
Are you a: British / United Kingdom citizen?
Yes No / If you are a national of another country, are you:
An EU National
A Refugee
An Asylum Seeker / A Student
Other (please specify)

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