.

Apply to the Health Panel

Health Panel Registration Form
(There is a lot of work done by locality and knowing your GP Practice will allow us to ensure you receive the right information)
The most efficient way to contact you is via e-mail. Is this right for you?
How would you like to be involved? (Please tick as many as you like)
Please note– you can change your level of involvement at any time

Equality Monitoring Form (strictly confidential)

Southern Derbyshire Clinical Commissioning Group recognises and actively promotes the benefits of diversity and is committed to treating everyone with dignity and respect regardless of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. To ensure that our services are designed for the population we serve, we would like you to complete the short monitoring section below. The information provided will only be used for the purpose it has been collected for and will not be passed on to any third parties.

Data Protection Statement

All information will be kept strictly confidential and in accordance with the Data Protection Act 1998 and associated protocols.

Equality Monitoring Form (strictly confidential)
What is your Postcode?
The first four letters/numbers of your postcode will help us understand where services may need to be directed (we will not be able to identify your address from this)
I'd prefer not to say
What is your Date of Birth?
I'd prefer not to say
Please choose one option that best describes your relationship status
Realtionship status
What is your Gender/Sex?
Gender
Have you gone through any part of a process (including thoughts or actions) to change from the sex you were described at birth to the gender you identify with, or do you intend to?
This could include changing your name, wearing different clothes, taking hormones or having gender reassignment
Please choose one option that best describes how you think of yourself
Sexual orientation
Giving help or support
Do you look after, or give any help or support to family members, friends, neighbours or others because of either:
Health conditions and illnesses
Are your day-to-day activities limited because of a health condition or illness which has lasted, or is expected to last, at least 12 months? (Please select all that apply)
Please choose one option that best describes your Ethnic Group or Background
White
Mixed/multiple ethnic groups
Asian/Asian British
Black/African/Caribbean/Black British
Chinese
Other ethnic group
Please choose one option that best describes your religious identity
Religious identity?
Please choose your preferred language option for communicating and intreptreting information
Preferred language

All Southern Derbyshire Clinical Commissioning Group Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals who require them.

For any questions or feedback regarding this form please contact Claire Haynes, Engagement Manager either by Phone: 01332 868677or Email: claire.haynes@southernderbyshireccg.nhs.uk