Patient Public Voice Group (PPV) Application Form - Haemoglobinopathy Coordinating Centre

Become a Patient Representative with the North East and Yorkshire Haemoglobinopathy Coordination Centre.

Download the role description >

Please fill out the below details to apply:

Title

If other, please specify

Full Name

Preferred name

Are you aged 18 or over?

Yes No

Address

Postcode

Area you live/Hospital you attend

Daytime contact telephone number

Mobile telephone number

Email Address

Position applying for

Chair SCD Patient and Parent/Carer Panel Deputy Chair SCD Patient and Parent/ Carer Panel Panel Member SCD Patient and Parent/Carer Panel Panel Member local Hospital Patient and Parent/Carer Panel

Please select the option that best applies to you

I am a Sickle Cell Disease patient I am a Carer /Parent of patient with Sickle Cell Disease, using health services Other (please state)

If other, please specify

Do you have any additional needs or need support from the NE&Y HCC Service to enable you to participate?

Yes No

If yes, please explain

Are you able to use email, Microsoft Teams/internet to communicate and take part in meetings? (We want to make our meetings as inclusive as possible so please let us know if you have any training or support needs.)

Yes No

Comments

Are you able to commit to the time commitment outlined in the application pack?

Yes No

Comments

Do you hold any other patient engagement roles? Please note that volunteers can hold a maximum of three roles that attract an involvement payment at any one time, and a maximum of five roles that do not attract a payment.

Yes No

If yes, please provide details

What impact has Sickle Cell had on you, child or family? (We suggest you do this in no more than 300 words)

Please tell us why you would be a good fit for the role? Please refer to the role profile and give specific examples of your skills, experience and knowledge in any work, volunteering or personal commitments.  (We suggest you do this in no more than 300 words)

Referee #1: Title

Referee #1: Full Name

Referee #1: Address

Referee #1: Postcode

Referee #1: Telephone No.

Referee #1: Mobile No.

Referee #1: Email Address

How do you know this person?

Referee #2: Title

Referee #2: Full Name

Referee #2: Address

Referee #2: Postcode

Referee #2: Telephone No.

Referee #2: Mobile No.

Referee #2: Email Address

How do you know this person?

Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months (include any problems related to old age)?

Yes, limited a little Yes, limited a lot No Prefer not to say

If you answered ‘yes’ to question 2, please indicate your disability

Vision (eg due to blindness or partial sight) Hearing (eg due to deafness or partial hearing) Mobility, such as difficulty walking short distances, climbing stairs, lifting and carrying objects Learning, concentrating or remembering Mental health Stamina or difficulty breathing Social or behavioural issues (eg due to autism, attention deficit disorder or Asperger’s syndrome) Other impairment Prefer not to say

What is your ethnic group?

If other, please specify

What is your gender?

Male Female Prefer not to say

Prefer to self-identify

Have you gone through any part of a process, or do you intend to (including thoughts or actions) to bring your physical sex appearance, and/or your gender role more in line with your gender identity? This could include changing your name, your appearance and the way you dress, taking hormones or having gender confirming surgery.

Yes No Prefer not to say

Other, Please Specify

Which of the following options best describes your sexual orientation?

Do you look after, or give any help or support to family members, friends, neighbours or others because of either long-term physical or mental ill-health/disability, or problems related to old age?

Data protection

The information provided on this application form will remain private and confidential and will be used for the purpose of selection. We may approach third parties such as your referees to verity the information that you have given. By signing this form, you are giving consent to all these uses.

Eligibility to volunteer

Individuals from outside the UK who volunteer with us are recommended to check their visa/entry clearance conditions before applying, to make sure they are allowed to do voluntary/unsalaried work.

Disclosure and barring: We ask everyone who works with vulnerable people in a voluntary capacity to disclose all convictions, including spent ones. This requirement is covered by the exemption order of 1975 relating to sections 4(2) and 4(3b) of the Rehabilitation of Offenders Act 1974. Do you have any criminal convictions/cautions?

Yes No

If yes, please attach any supporting documents. Please note, a criminal record will not necessarily prevent you from working with us; however, we reserve the right to conduct checks as necessary with the Disclosure and Barring Service (DBS).

Declaration

The statements made by me in this application are to the best of my knowledge true. I confirm I have read and understood the information above.

Why we are asking you to complete this form

N E & Y HCC is committed to promoting equality and eliminating unlawful discrimination, and we are aiming to achieve diversity in the range of people we involve. You do not have to answer these questions, and we understand that some of this information is personal and sensitive in nature. However, gathering this data helps us to know if we are succeeding in involving different groups of people, and to change our approach if some groups are not represented.

Data protection

The information you provide is anonymous and will not be stored with any identifying information about you. We may use anonymised statistics and data to inform discussions about improving the diversity of our patient safety partners and inclusivity of participation opportunities, but no information will be published or used in any way which allows an individual to be identified. All details are held in accordance with the Data Protection Act 1998.

The information that we are asking you to provide is informed by our duties under the Equality Act 2010, and includes information about your age, race, sex and sexual orientation.

If you would like this information in an alternative format, or would like help in completing the form, please contact us.