PATIENT EXPERIENCE FEEDBACK is Invited and Encouraged

To Highlight the Importance of the Armed Forces Covenant

PATIENT INFORMATION SHEET

We are very interested in hearing about varying experience accounts to showcase the benefits for Armed Forces Personnel and their families when the Covenant has been correctly adhered to and also, to balance this, accounts to demonstrate the negative impact when it has been ignored.

Your insights about your experience which can be sent directly by email to the address shown below may therefore be sharedwith:

  • other Shropshire CCG staff
  • staff at local hospitals
  • via SCCG Board meetings on 9 November 2016 and therefore with the public
  • SCCG partners for example local authority or voluntary sector
  • Via the SCCG’s website

While we may talk about aspects of your experience, you retain the option to not be identified (by name or by sharing circumstances that may be identifiable to you as an individual) on the website, in any reports, presentations or associated papers.

In sharing your insights about the health system, any information that you provide us with or we collect about you via interview will remain confidential, and will accordingly be disclosed only withyour permission.

You also have the option to nominate an ‘alias’ so that references to the information you provideus will not identify you.

In the event that you have any concerns or questions or would prefer to discuss your experience direclty please feel free to contact us directly:

Contact name: Jane Blay

Position/title: Patient Experience Lead

Phone: Direct Dial 01743 277665

E-mail:

Thank you for taking the time to share your experience with Shropshire Clinical Commissioning Group

Please retain this information sheet for future reference.

PARTICIPANT CONSENT FORM

  • I hereby give my consent that details of my recent experience of Shropshire Clinical Commissioning Group and/or the services commissioned by them provided by myself can be shared as outlined in the Patient Information Sheet.
  • I agree to participate in an interview regarding my recent experience with the SCCG and/or services commissioned by them.
  • I consent to taking part in the discussion and have understood the information containedwithin the Patient Information Sheet.
  • I understand I can withdraw my comments at any time and do not have to give any reasonfor withdrawing. I also understand that I may be contacted in the future as part of anevaluation of this patient interview method.
  • I understand that my personal information will remain confidential as outlined in the

Patient Information Sheet, a copy of which I will retain for my record.

Print Name: ______Date: ______

Signature: ______Telephone: ______

Alias if Preferred : ______

Name of SCCG Representative: Jane Blay

Signature: ______

I have informed the above person about this interview and I am sure that they understand

the content of both the Participant Information Sheet and this Participant Consent Form.

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