Application Form: CCG Patient Reference Group

Name
Postal address
Phone number
Email
Why would you like to have a say in local health services?
Are you a member of any other patient groups or health communities?
Would like to tell us about an experience of a health service in Waltham Forest?
What knowledge and / or skills do you think you could bring to this group?

On the next page we have asked some Equality and Diversity questions.

We are asking these questions because we want both our new groups to be representative of the diversity in Waltham Forest, and this information will help us ensure this is the case.

You don’t have to answer these questions if you don’t want to. It won’t affect your chances of joining the group.Age /  Under 21  21-30  31-40  41-50  51-60  61-64  65 and over
 I do not wish to disclose this
Gender /  Male  Female  Transgender  I do not wish to disclose this

Race relations (Amendment) Act 2000

I would describe my ethnic origin as:
Asian or Asian British
 Bangladeshi
 Chinese
 Indian
 Pakistani
 Vietnamese
 Any other Asian background
Please specify:
Black or Black British
 Caribbean
 Somali African
 Other African
 Any other Black background
Please specify:
/ Mixed
 White & Asian
 White & Black African
 White & Black Caribbean
 Any other mixed background
Please specify:
White
 British
 Irish
 Any other White background
Please specify:
 I do not wish to disclose this
Please state your Nationality
Please state your Country of Birth

Disability Discrimination Act 2005

Under the Disability Discrimination Act 2005 a person is considered to have a disability if he/she has a physical or mental impairment which has a sustained and long-term adverse effect on his/her ability to carry out normal day to day activities.

Do you consider yourself to have a disability? /  Yes  No
 I do not wish to disclose this
Please state the type of impairment that applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘Other’ and specify the type of impairment:
 Physical impairment
 Sensory impairment
 Mental health condition
 I do not wish to disclose this /  Learning disability/difficulty
 Long-standing illness
 Other
Please specify:
Please select the option which best describes your sexuality
 Lesbian/gay woman
 Gay man
 Bisexual /  Heterosexual/straight
 I do not wish to disclose this
Please indicate your religion or belief
 Agnostic
 Atheism
 Buddhism
 Christianity
 Hinduism
 Islam
 I do not wish to disclose this /  Judaism
 Sikhism
 Other
Please specify:
 I do not wish to disclose this
Locality: / Walthamstow / Chingford / Leyton and Leytonstone /
Which health conditions do you have experience of? / Chronic Obstructive Pulmonary Disease / Diabetes / Dementia /
Cardiovascular Disease / Cancer / Mental Health problems /
Prefer not to say
Other: