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Beds and Luton Chrildrens Working Together Contact

Would you like to help make a difference to patients and families like yours?   Do you have the time to come and join us to talk about your ideas, and share thoughts about how we can improve the health care that we deliver?  Please leave your details below and one of our team will be in touch.



Beds and Luton Chrildrens Working Together Contact

Your details
1Title:
2Name:
3Age of your child or young person?
4Address:
5Telephone:
6Email:
7How would you prefer to be contacted?
Telephone
  Email
SMS text
 
8Do you require an interpreter?
YesNo
9What is your first language?
10Your availability:
Monday AM
  Monday PM
Monday Evening
  Tuesday AM
Tuesday PM
  Tuesday Evening
Wednesday AM
  Wednesday PM
Wednesday Evening
  Thursday AM
Thursday PM
  Thursday Evening
Friday AM
  Friday PM
Friday Evening
  Saturday AM
Saturday PM
  Saturday Evening
Sunday AM
  Sunday PM
Sunday Evening
 
11Please tell us about any additional support that you might need from us to take part

Area of Particular Interest
12Which services have you had experience of?
0-19 Service (Health Visiting and School Nursing)
  Audiology
Children's Community Nursing
  Community Paediatrics
Eye Service
  Infant Feeding Team
Nutrition and Dietetics
  Occupational Therapy
Rapid Response
  Special Needs Nursing
Speech and Language Therapy
  None
Other (please specify) If you are wishing to participate in a specific involvement activity, please state here.
 

Ethnicity
13Please state your ethnicity:

14Your details will be held securely and not shared. For more information about our use of your data go to: www.cambscommunityservices.nhs.uk/privacy-notice
I provide my consent for my data to be kept safely and securely and in accordance with the Trust privacy statement available on the web address above.
YesNo
15I will uphold the confidentiality of all information, including that of staff and service users.
YesNo
16You do not have to take part in any of the activities, surveys or meetings that we invite you to. Your point of contact is the Co-production Team, they can be contacted at ccs.co-production@nhs.net.

I understand that I can decline future correspondence at any time or opt out of my data being stored by contacting the Co-production Team.
YesNo

We would be very grateful if you could answer some questions about you. You may wonder why we ask personal questions, or fear that your answers could affect your involvement in a negative way; in fact, the more you tell us about you, the greater opportunity we have for recognising the value of your particular perspective. Responding to these questions is entirely voluntary and any information provided will remain anonymous and treated in the strictest confidence.

Please answer the following questions about yourself.
17Are you happy to answer some additional questions?
YesNo
18What is your postcode:
19Please tell us your age.
05-1112-1718-2526-3536-4546-5556-6565+I do not wish to disclose my age
20What is your relationship status?
21Are you currently pregnant?
YesNoI do not wish to disclose
22Have you given birth within the last 12 months?
YesNoI do not wish to disclose
23Do you consider yourself to have a disability or long term condition? This includes any health condition or disability that impacts on your daily life which you have had for 12 months or more. You may have learnt to manage your disability/long-term condition, but it still counts.
YesNoI do not wish to disclose whether or not I have a disability or long term condition
24How would you describe your disability or long term condition?
25Ethnicity
Asian or Asian BritishBlack or Black BritishMixedWhiteOther Ethnic GroupI do not wish to disclose my ethnic origin
26Asian or Asian British
BangladeshiIndianPakistaniAny Other Asian Background
27Black or Black British
AfricanCaribbeanAny other Black Background
28White
White BritishWhite IrishAny other white background
29Mixed
White and AsianWhite and Black AfricanWhite and Black CaribbeanAny Other Mixed Background
30Other Ethnic Group
ChineseGypsyRomaIrish TravellerAny Other Ethnic GroupI do not wish to disclose my ethnic origin
31Are you:
FemaleMaleNon-binaryPrefer to self-identifyI do not wish to disclose my gender
32Is your gender identity the same as the gender you were given at birth?
YesNoI do not wish to disclose
33Sexual Orientation
BisexualGayHeterosexual / StraightLesbianPrefer to self-identify, please specify belowI do not wish to disclose my sexual orientation
34Religion or Belief