NHS Hastings and Rother Clinical Commissioning Group
Chair – Dr David Warden Chief Officer – Amanda Philpott
NHS Eastbourne, Hailsham and Seaford Clinical Commissioning Group
Chair – Dr Martin Writer Chief Officer – Amanda Philpott
Expression of interest
Patient Representative for the Quality and Governance Committees
meeting together
Please send your completed form to reach us no later than 31 August 2016:
By email: [email protected]
By post: Kerry Smith, NHS Hastings and Rother CCG, Bexhill Hospital, Holliers Hill,
Bexhill-on-Sea, East Sussex, TN40 2DZ
Black ink is preferred so that it is as clear as possible.
Your personal details
Full name
Address
E-mail address
Day time telephone
number
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
1. Present and previous employment
Where relevant, please include the name and address of the person or organisation where
you have worked and dates of employment. The work may have been in a paid or
voluntary capacity. Please continue on a separate sheet if necessary.
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
2. Education and qualifications
Where relevant, please indicate dates of qualifications and name of institution.
3. Training
This could include training schemes, short courses, projects, secondments,
trade/professional training. Please give date of completion.
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
4. References
Please give the details of two people who can give a reference concerning your character
as well as your work with adults.
First reference
Name
Address
Telephone
Number
Occupation
Tell us how you
know this person
Second reference
Name
Address
Telephone
Number
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
Occupation
Tell us how you
know this person
5. Warnings and disciplinary issues
a) Have you ever been dismissed, or have you ever resigned in the face of a dismissal
or warning?
Yes / No
b) Have you ever been the subject of an allegation or conviction in relation to the
safety and welfare of children, young people and/or vulnerable adults, either
substantiated or unsubstantiated?
Yes / No
If you have answered yes to either of the above questions, you must supply details and
attach them separately.
c) List any disciplinary offences or warnings you have received at any time
6. Availability/ Attendance
If appropriate, please give information about anything that might impact on your regular
attendance at the Committee meetings or to read and complete work virtually (telephone
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
and email). This could be an existing regular commitment you have, a health condition or
something else.
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
7. Why are you applying for this role?
Please mention any specific skills or experience that meet the requirements of the role
description. These skills may have been gained in relation to your current or previous
employment, education, training, domestic activities, or voluntary work. Maximum of
500 words. Please continue on a separate sheet if necessary.
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
Declaration
I declare that the information given on this application form is true and correct. I
understand that any false or misleading information, or omission of information, may
disqualify my application.
Signed
Date
Print name
Details about how and where to send your completed form, are on page 1 of this form.
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
We want to make sure that everyone is treated fairly and equally and that no one gets left out. That's why we
ask you these questions. We won't share the information you give us with anyone else. We will only use it to
help us make decisions and make our services better. If you would rather not answer any of these questions,
you don't have to.
Q1
Which council area do you live in?
☐ Hastings
Q2
☐ Rother
☐ Eastbourne
Are you......? Please select one box
☐ Male
Q3
☐ Female
Q5
☐ Prefer not to say
Do you identify as a transgender or trans person? Please select one box
☐ Yes
Q4
☐ Wealden ☐ Lewes ☐ None of these
☐ No
☐ Prefer not to say
Which of these age groups do you belong to? Please select one box
☐ under 18
☐ 25-34
☐ 45-54
☐ 60-64
☐ 75+
☐ 18-24
☐ 35-44
☐ 55-59
☐ 65-74
☐ Prefer not to say
To which of these ethnic groups do you feel you belong? (source: 2011 census)
Please select one box
☐ White British
☐ Asian or Asian British Indian
☐ White Irish
☐ Asian or Asian British Pakistani
☐ White Gypsy/Roma
☐ Asian or Asian British Bangladeshi
☐ White Irish Traveller
☐ Asian or Asian British other*
☐ White other*
☐ Black or Black British Caribbean
☐ Mixed White and Black Caribbean
☐ Black or Black British African
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
☐ Mixed White and Black African
☐ Black or Black British other*
☐ Mixed White and Asian
☐ Arab
☐ Mixed other*
☐ Chinese
☐ Other ethnic group*
☐ Prefer not to say
*If your ethnic group was not specified in the list please
describe your ethnic group.
The Equality Act 2010 describes a person as disabled if they have a longstanding physical or mental
condition that has lasted or is likely to last at least 12 months; and this condition has a substantial adverse
effect on their ability to carry out normal day to day activities. People with some conditions (cancer, multiple
sclerosis and HIV/AIDS, for example) are considered to be disabled from the point that they are diagnosed
Q6
Do you consider yourself to be disabled as set out in the Equality Act 2010?
Please select one box
☐ Yes
Q7
☐ No
☐ Prefer not to say
If you answered yes to Q6, please tell us the type of impairment that applies to you.
You may have more than one type of impairment, so please select all that apply. If none of these apply to you
please select other and give brief details of the impairment you have.
☐ Physical impairment
☐ Sensory impairment (hearing and sight)
☐ Long standing illness or health condition, such as cancer, HIV, heart disease, diabetes or epilepsy
☐ Mental health condition
☐ Learning disability
☐ Prefer not to say
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk
☐ Other*
*If other, please specify
Q8
Do you regard yourself as belonging to any particular religion or belief?
Please select one box
☐ Yes
Q9
☐ No
☐ Prefer not to say
If you answered yes to Q8 which one? Please select one box
☐
Christian
☐ Buddhist
☐ Hindu
☐ Muslim
☐ Jewish
☐ Sikh
☐ Any other religion, please specify
Q10 Are you... Please select one box
☐ Bi/Bisexual
☐ Gay woman/Lesbian
☐ Other
☐ Heterosexual/Straight
☐ Gay Man
☐ Prefer not to say
www.hastingsandrotherccg.nhs.uk
www.eastbournehailshamandseafordccg.nhs.uk