Experience of Care Proforma (Patient Partner/Carer and NHS Staff) 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 choicePatientService UserCarerStaffAll of the aboveOtherNot ProvidedN/AName* Mr.Mrs.Miss.Ms.Dr.Prof. Salutation First Last Address*City* Postcode* Landline Mobile Preferred Contact MethodEmailMobilePhonePostEmergency Contact (Primary)Name* First Last Relationship to you* Home Phone Mobile* Email* Emergency Contact (Secondary)Name First Last Relationship to you Landline Mobile 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*Please Select...FemaleMaleDo Not Wish to DiscloseNot ProvidedGender Identity*Are you now or have you ever defined yourself as Trans? Please Select...YesNoDo not wish to discloseAge*Please Select...14-1718-3536-5051-65Over 65Do not wish to discloseNot ProvidedParental / Legal Guardian/ Carer consent to volunteerAs 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. Name* First Last Email* Phone*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:Please Select...White BritishWhite IrishWhite - any other backgroundMixed - Black - Black British CaribbeanMixed - Black - Black British AfricanMixed - White - AsianAny other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAny other Asian backgroundBlack or Black British - CaribbeanBlack or Black British - AfricanBlack or Black British - Any other backgroundAfricanCaribbeanArabOther Ethnic group - ChineseDo not wish to discloseDo you consider yourself to have a disability?* None Visual impairment Hearing impairment Disability affecting mobility Other physical disability Other medical condition (for example epilepsy, asthma, diabetes) Emotional/Behavioural difficulties Mental health difficulty Temporary disability after illness (for example post-viral or accident) Profound complex disabilities Asperger's syndrome Other Do not wish to disclose Other Disability Do you require any additional support to enable participation?Please Select...YesNoDetails/ Access Requirements:N/AMissing Section on formNote takerLarge printInterpreting servicesWheelchairHighchairAdditional support details: Translator / Interpreter required (please tick if required) Translator/ Interpreter language: Specific Dietary Requirements e.g. vegan, vegetarian, allergies Would you be willing to record your story in advance for use in virtual delivery of our programmes?*Please Select...YesNoThis 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?*Please Select...YesNoThis 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. Platforms for Digital Programme DeliveryWe use Microsoft Teams or Zoom for the delivery of our programmes online.How it WorksAs 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.As educators and storytellers, patients, service users and carers 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. They are supported throughout the session, as it can often get emotional. Storyteller/Educator role As educators and storytellers, patients, service users and carers 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. They are supported throughout the session, as it can often get emotional. 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 assess whether from their perspective, the patients 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. 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 assess whether from their perspective, the patients 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.We support our NHS Leaders as part of their Leadership Development Programmes and personal leadership journey across the health and care system. 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. As part our work, we support our NHS colleagues when they are recruiting and interviewing people to NHS jobs. Interviewers As part our work, we support our NHS colleagues when they are recruiting and interviewing people to NHS jobs. 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. 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. 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. 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 work alongside Academy and faculty staff to support the delivery of leadership development and lifelong learning. Delivery Partner Delivery Partners work alongside Academy and faculty staff to support the delivery of leadership development and lifelong learning.Patient Partners and CarersThis section to be completed for Experience of Care, Patient Partners and Carers - Thank youPlease share your story, your personal experience/s with NHS services, whether it is positive or negative, all feedback has an impactful contributionYour 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?NHS StaffPlease complete below if you are NHS Staff - Thank youJob Title Job Role Organisation (NHS Staff only) Have you participated in an Academy programme before?YesNoName 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?band 1band 2band 3band 4band 5band 6band 7band 8aband 8bband 8cband 8dband 9VSAN/ANHS Staff TypeSelect Control and Click to select multiple choiceClinicalNon-ClinicalOfficeAdminProjectAncillary StaffOtherPlease give further details of other roles/responsibilities you may be currently involved withA 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?Are you involved in other patient partner roles through NHS England & Improvement?*YesNoIf yes, what other roles are you involved in?Thank youThank you for your time in completing this Proforma. Please do not hesitate to contact the team with any questions. Email: pfcp@leadershipacademy.nhs.uk Email Post Title