HQIP / Service User Network Form

Service User Network Form

We welcome all people with lived experience of using healthcare services as patients and/or carers to join our Service User Network by filling out the form below. This will help us understand your experiences and interests so we can engage with you effectively and target involvement activities.

In order to ensure diverse membership and to meet the aims and commitments set out in our Equity, Diversity and Inclusion policy, the form does ask questions about gender, ethnicity, and health conditions. You will have the option to choose not to respond to these questions, but please be assured that if you do respond, your information will stay confidential and will be stored securely and limited to only the staff involved in facilitating the Service User Network.

If you have any questions about the Service User Network or the form, please email our Head of Patient and Carer Engagement, Kim Rezel: [email protected]

Form

Name *

Experience* (Please describe your experiences of using health care services - please list the areas of care that you have experienced eg. stroke services, mental health services, maternity, diabetes etc.)

Interest* (Consider the engagement work that you would like to be involved in e.g. reviewing, presenting, advocacy at meetings and events etc.)

What gender do you identify as?

What is your age?

Which region do you live in?

If you chose 'other', please state:

What is your ethnicity?

If you chose 'other' background, please state:

Do you have a disability (physical, mobility, mental health, learning, developmental, communication) or live with a health condition?

If you chose 'yes', please describe:

Do you identify as neurodivergent?

If you chose 'yes', please describe:

Are you deaf or hard-of-hearing?

How did you hear about the Service User Network?

Please describe:

Telephone number *

Email address *

Data Protection Statement

For the purposes of the Data Protection Act 2018 and GDPR, your personal data will be processed (including the collection, retention, use and disclosure) (both electronically and manually) by HQIP (or a third party appointed by the Company for such purposes) for purposes relating the management, security and administration of the activities of the organisation. Any sensitive information you have provided above (such as ethnicity, age, sex or health data) will be used only to ensure our User Panel is representative of users and carers of services across England.

By registering your interest, you are agreeing to receive emails with updates about participation opportunities related to the Service User Network. You will be able to opt out from receiving emails at any time by contacting [email protected]

Our privacy notice is regularly updated on the HQIP website and provides further detail on the bases and purposes for processing your information. It also states how you can exercise your individual rights.

Please tick to agree to confirm you have read our privacy notice.