Have your say - Become a locality member

To help us keep you informed about issues that are relevant and of interest to you please complete the form below.

West Essex Clinical Commissioning Group is seeking volunteers of all ages and backgrounds with an interest in the NHS - people who want to do something meaningful to improve health services and make change happen

As a locality member you will have opportunities to get involved at different levels according to what suits you and the time you have available:

Level 1 – We will send you information and invite your comments on health service decisions in their early proposal stages
Level 2 – Take part in workshop sessions to help redesign local health services
Level 3 – Become a local agent to communicate health information and gather feedback from local communities.

There is no deadline for applications.

Please feel free to encourage your friends and family to join as well!

Title

Forename

Surname *

Address 1 *

Address 2

Town *

County *

Postcode *

Telephone number

Email Address

GP Practice (optional)

Which locality area are you interested in joining

Tick this box if you would like to join the Locality Forum group for your area

Do you belong to a voluntary group or similar?

Yes
No

If yes, please give the name of the voluntary organisation that you belong to

How would you like to be involved? *

Level 1
Level 2
Level 3

Level 1 – We will send you information and invite your comments on health service decisions in their early proposal stages
Level 2 – Take part in workshop sessions to help redesign local health services.
Level 3 – Become a local agent to communicate health information and gather feedback from local communities

Equality monitoring

Your information in this section will be treated in confidence. This information is for monitoring purposes only and will help us to ensure that people have an equal opportunity to give their views.

Sex

Male Female

Do you consider yourself to have a disability?

Yes No

The information you provide below will be used to contact you in future, however, if you do not wish to be contacted via any of these methods (eg. phone, text, email) please leave that particular line blank. The privacy and confidentiality of your information is important to us. As an organisation we adhere to the principles of the Data Protection Act and NHS Confidentiality Code of Conduct detailed below.

The information supplied in this form will be kept for 2 years, will only be used for locality membership purposes and will be treated with complete confidentiality under the Data Protection Act i.e. it will not be shared with third parties. The Data protection Act 1998 regulates the collection, storage, processing and disclosure of personal data and also gives rights to individuals about whom information is recorded.

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