PATIENT FACULTY, CODESIGN & PRACTICE – PROFORMA – PATIENT PARTNER, CARER AND NHS STAFF

Please can you complete and submit the form.

This form is available in alternative formats and languages, please contact pfcp@leadershipacademy.nhs.uk

Please note:

We use leading technologies and encryption software to safeguard your data and keep strict security standards to prevent any unauthorised access to it.

GDPR: To ensure your data is secure, all the details provided are protected by the GDPR as applicable 25 May 2018. We use leading technologies and encryption software to safeguard your data and keep strict security standards to prevent any unauthorised access to it.

GDPR as applicable 25 May 2018*
Yes
Please identify which is applicable (You can select more than one)*Select Control and Click to select multiple choice
Name*
Title First Name Last Name
Primary Address Street*
Primary Address City*
Primary Address Postcode*
Landline
Mobile*
Email Address*
Preferred Contact Method
Emergency Contact (Primary)
Emergency Contact Name*
Emergency Contact Relationship*
Emergency Contact Home Phone
Emergency Contact Mobile*
Emergency Contact Email*
Secondary Emergency Contact
Secondary Emergency Contact Name
Secondary Emergency Contact Relationship
Secondary Emergency Contact Home Phone
Secondary Emergency Contact Mobile
Secondary Emergency Contact Email
Equality and diversity:
The intention of capturing demographics is to ensure representation of NHS patients, service users, carers and staff across genders, ages and people with disabilities. If there are differences in opportunities it will enable action to be taken to ensure that no group is excluded. Your answers will be treated confidentially.
Gender*
Are you now or have you ever defined yourself as Trans?*
Age Group*
Ethnic Origin*Groups based on the Government recommendations. There are 5 main groups: White; Mixed/Multiple ethnic groups; Asian/Asian British; Black/African/Caribbean/Black British; Other ethnic groups. Please select below which ethnic group you identify with:
Do you consider yourself to have a disability? (Hold down Ctrl key and click to select multiple)
Other Disability
Do you require any additional support to enable participation?
Details / Access requirements
Additional Support Details
Need a Translator/Interpreter?

Yes

No
Translator/ Interpreter language:
Special Dietary Requirements e.g. vegetarian, vegan, allergies
Would you be willing to record your story in advance for use in virtual delivery of our programmes?*
This would mean we use a recording of your story rather than you telling your story live to the participants on the day. We would then show your recording as part of the programme.
Would you be willing to tell your story live online as part of the virtual delivery of our programmes?*
This would mean you would be invited to join the virtual delivery of the programme session to share your story live with the participants. This would be via Microsoft Teams or Zoom typically.
Parental / Legal Guardian/ Carer consent to volunteer
As a young volunteer under the age of 18, we require consent from your parent, legal guardian or carer for you to volunteer with the Leadership Academy. Please complete their contact details below.
Parent/Guardian Name
Parent/Guardian Email*
Parent/Guardian Contact Number*
Platforms for Digital Programme Delivery
We use Microsoft Teams or Zoom for the delivery of our programmes online.
How it Works
As part of our leadership development programmes patients, carers and staff are invited to talk about their positive or negative experiences with participants on the programmes. With facilitation, these stories then become discussion areas for the patients and participants during their experiential learning. Find below descriptions of the various roles you can take on as a Patient, Carer or NHS Staff Partner.
Storyteller/ Educator Role
As educators and storytellers, patients, carers, service users and NHS staff can share their experiences of care – positive and negative – with leaders undertaking development programmes. The storyteller has some preparation to do and is debriefed afterwards.
Assessor
During our senior leadership development programmes, the participant is required to undertake an assessment. This is conducted by NHS frontline staff and patients with a chair from the organisation. Patients and staff partners assess whether from their perspective, the programme participants have credibility as a Senior Leader and whether they have truly engaged in the learning to bring about changes to patient care and staff engagement.
Coaches and Mentors
We support our NHS Leaders as part of their Leadership Development Programmes and personal leadership journey across the health and care system
Interviewers
As part of our work, we support our NHS colleagues when they are recruiting and interviewing people to NHS jobs.
People Champions
People champions support the strategy of the organisation and, from their positions of experience in senior arenas, can guide our decision-making. Their role is like the activity undertaken by patient advisory forum (PAF) members.
Programme and Practice Board Members
All Academy programmes have a programme and practice board. The purpose of the board is governance, but also continuous quality improvement based on evaluation and feedback from participants. Patients are very active in all boards.
Delivery Partners
Delivery Partners work alongside Academy and faculty staff to support the delivery of leadership development and lifelong learning.
Please select from the list below the role(s) you would like to undertake as a Patient or Staff Partner (hold down Ctrl key and click to select multiple):
Patient Partners and Carers
This section to be completed for Experience of Care, Patient Partners and Carers – Thank you
Please share your story, your personal experience/s with NHS services, whether it is positive or negative, all feedback has an impactful contribution*
Your experience of the COVID 19 PandemicWe would be interested in hearing of your experience of the COVID 19 Pandemic and how it has affected your life as a Patient, Carer, Service user or NHS Staff. Please share with us your story in the box below.
Are you involved in other patient partner roles through NHS England & Improvement?*
If yes, what roles are you involved in?
NHS Staff
Please complete below if you are NHS Staff – Thank you
Job Title*
Job Role
Organisation (NHS Staff only)*
Have you participated in an Academy programme before?*
Name of the Programme

If you have participated in an Academy programme before, what programme was it?
When did you attend the programme?
What is your pay band?*
NHS Staff Type*Select Control and Click to select multiple choice
Please give further details of other roles/responsibilities you may be currently involved with
A brief resume of your background and experience with the NHS (negative or positive)*
Your experience of the COVID 19 PandemicWe would be interested in hearing of your experience of the COVID 19 Pandemic and how it has affected your life?
Thank you
Thank you for your time in completing this Proforma. Please do not hesitate to contact the team with any questions. Email: pfcp@leadershipacademy.nhs.uk

Save and Continue Later

Please note:

Emergency Contact (Primary)

Secondary Emergency Contact

Equality and diversity:

Parental / Legal Guardian/ Carer consent to volunteer

Platforms for Digital Programme Delivery

How it Works

Storyteller/ Educator Role

Assessor

Coaches and Mentors

Interviewers

People Champions

Programme and Practice Board Members

Delivery Partners

Patient Partners and Carers

NHS Staff

Thank you