Patient and Public Panel Sign Up Form

To give patients and the public a voice and ensure their views are acted upon, North West Ambulance Service (NWAS) has established a Patient and Public Panel.

Made up of representatives from local communities, the panel offers meaningful opportunities to influence improvements in NWAS’ emergency, patient transport and 111 services.

Varying levels of participation enable people to get involved in a way that suits them best, depending on the amount of time and level of interest they have. It can even be done virtually!

Anyone who lives in Greater Manchester, Merseyside, Cheshire, Glossop (Derbyshire), Lancashire or Cumbria can apply to join.

Applications are welcome from people over the age of 16 from all backgrounds, beliefs, cultures and circumstances to ensure the panel is representative of the communities served by North West Ambulance Service.

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* 1. First name

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* 2. Last name

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* 3. Telephone number

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* 4. Email address:

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* 5. Which county do you live in?

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* 6. Are you curently employed with us at North West Ambulance?

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* 7. Have you used North West Ambulance Service before? If so which service did you use most recently?

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* 8. Have you ever raised a complaint or do you have an ongoing complaint with an NHS Organisation?

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* 9. Please tell us why you are interested in joining the panel?

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* 10. What skills and experience could you bring to the panel?

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* 11. What does confidentiality mean to you?

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* 12. Which level of involvement would you prefer?

  First choice Second choice Third choice
Influence 
Taking an ongoing, active role in high-level meetings and committees to enhance decision making and discussions (support and mentoring will be provided).
Co-produce 
Contributing to focus groups or meetings by providing opinions, experience and expectations to help inform improvements and review how services or initiatives are planned and delivered.
Consult
Responding to surveys, giving feedback on strategies, initiatives and publications and providing thoughts on events and campaigns on an occasional basis, often virtually.
Demographic Information – Please provide some demographic information for us below if you wish to.  This will help us to ensure that our Patient Panel is representative of the community that we serve.

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* 13. Age:

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* 14. What is your gender?

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* 15. North West Ambulance Service is committed to equal opportunities for all. If you have a disability, health problem or English is not your first language, please give details below of any services or support that you would like us to provide in order for you to become involved.

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* 16. What is your ethnicity?

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* 17. Where did you hear about the panel?

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* 18. I consent to North West Ambulance Service contacting me using the details I have provided above in relation to its Patient and Public Panel. I also understand I can withdraw this consent at any time by contacting patient.panel@nwas.nhs.uk

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