Citizen Panel Membership Form

Do you want the best possible health services for people in with ? Do you want to help shape those services in the future?

We want to find out which services need protecting/preserving and which can be delivered in a different way – whilst still meeting the needs of our residents. Your opinion matters to us. Your feedback helps ensure that we are planning and buying the right local services for you.

To be most effective, we recognise we need to reach out and listen to as wide a range of people from across as possible.

You can help by becoming a member of our Citizen Panel. This is a membership scheme for people who are interested in sharing their views and experiences to help to develop and improve services locally. It is an exciting new way to have your say and influence decision-making on a whole range of health services that are important to people in Blackburn with Darwen. You can join by filling in the form below, and over the page.

Four times a year we will randomly pick a selection of 250 members to speak to. Everyone who takes part will be entered into a prize draw and 25 people will receive a £10 voucher which can be used in leisure centres in Blackburn with Darwen or at the box office at King George’s Hall or Theatre. This is a thank you for taking the time to get involved.

Please complete:

Name …………………………………………………………………………………………………………………………………………………………………………………..

Address ………………………………………………………………………………………………………………………………………………………………………………..

Email …………………………………………………………………………………………………Telephone………………………………………………………………

GP Practice………………………………………………………………………………………………………………………………………………………………………….

Areas of interest - please tick as many as you like

Respiratory Alcohol End of life care   (asthma, COPD)  Cancer  GP practice  Social care  Carers  Heart and chest  Stroke  Dementia  Local hospital  Urgent care / A&E  Children/young people & Mental health Other (please state) families   Learning Disability  Diabetes  Health and Well Being  Ophthalmology (eyes)  All 

We want to ensure that we engage with you in the channel of your choice. How do you want us to engage with you as a member of the Citizen Jury? Tick as many as apply

Digital – online closed group Post   Email Face to face group meetings   Telephone 

I represent a patient / carer / community group (please circle as appropriate) .

Name of community group (optional):

Please indicate your answers below with an X:- White British Mixed White & Black Caribbean Irish multi White & Black African Polish ethnic White & Asian Other European, please state Arab

Other, please state Other, please state

Asian Indian Chinese or Chinese or Pakistani other Philippine Asian Bangladeshi ethnic Vietnamese British Other, please state groups Thai Other, please state

Black Caribbean Gypsy & Irish African Traveller Romany British Other, please state Other, please state

Any other ethnic or nationality background not listed, please state:

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What is your age category?

0 - 10 11 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 70 71 - 80 81 and over

What is your gender?

Male Female Other Rather not say

Do you consider yourself to have a disability? (The Equality Act 2010 states a person has a disability if they have a physical or mental impairment which has a long term (12 month period or longer) or substantial adverse effects on their ability to carry out day to day activities).

Physical impairment (please state) Sensory impairment (please state) Mental health need Learning disability or difficulty Long term illness (please state) Other, please state

Thank you for completing this form

Data Protection Act 1998 The information you provide on this form will be used by Blackburn with Darwen Clinical Commissioning Group (CCG) to contact you about local health care services, activities and to inform you of the ways in which you can get involved. We will also inform you of events being run by our partner agencies. Midlands and Commissioning Support Unit (CSU) are managing the membership scheme on behalf of the CCG and will have access to your data.

Your details will only be used for this purpose and will not be shared with anyone else. The information you supply will be held securely and in accordance with the Data Protection Act 1998. You can opt out of the membership scheme at any time by e-mailing [email protected] We will contact you for your consent if there are any changes to the way in which your information is used.

I agree 

For assistance in completing the form, please contact Communications Manager Lucie Higham on 07469377840 or email [email protected]

Please post to Citizen Panel, Blackburn with Darwen CCG, Fusion House, Evolution Park, Haslingden Road, Blackburn, BB1 2FD.

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