Application form Role: Public Reference Group member Introduction We are recruiting people to join our Public Reference Group. The Public Reference Group (PRG) supports the CCG to ensure public and patient involvement is at the heart of our commissioning and business functions. Membership of the Public Reference Group To be eligible for a place on the PRG, you must live in the borough of Lewisham and/or work in association with Lewisham health services and/or, have experience of Lewisham health services. You should also have a positive commitment to helping us improve local health services. The PRG consists of individuals recruited to this role who will reflect Lewisham’s diversity. Meetings usually take place once every six weeks. There will be some training and induction sessions for new members. On average, we would expect the role to have approximately five hours commitment per month. There will be a payment for participation and attendance at the meetings and training. It is the individual’s responsibility to ensure that any incentive payment made does not affect their benefits entitlement, tax or national insurance position. The application form should be completed and returned by noon on Tuesday 31 July 2018. The first round of interviews is scheduled for 21st June 2018. If you would like further information, please phone Teresa Rodriguez, Engagement Officer on 020 3049 3208 or email . Application form for Public Reference Group Personal details Title (Mr, Mrs, Ms, Miss,etc) First Name Surname/Family Name
Please give us the details of two people who would be willing to be a referee for you. Referee 1 Name: Organisation (if relevant): Address: Telephone: Email address: How do you know this referee? Referee 2 Name: Organisation (if relevant): Address: Telephone: Email address: How do you know this referee? Rehabilitation of Offenders Act 1974 If you have previously been convicted of any offences, please give details below, unless the conviction can be regarded as ‘spent’ in terms of the Rehabilitation of Offenders Act 1974. If you have no convictions please write NONE. …………………………………………………………………………… Conditions of involvement at Lewisham CCG When you are present in any of the CCG’s buildings or grounds you must follow certain policies, including: Health and Safety Equality and Diversity policies Guidelines about using telephones, computers, internet and email. Confidentiality You will not have access to patient, volunteer of staff information. However, you must understand that if any personal information is inadvertently made available to you this must remain absolutely confidential and reported to the appropriate member of staff. If you discuss such information with anyone, we will not allow you to continue working with us. Breaking confidentiality may also result in someone taking civil action against you. DECLARATION I have read and understood the above statements. I agree to be involved in the Public Reference Group and agree to the conditions. I consent to the information given on the form being entered onto the Patient Engagement database. It is my responsibility to ensure that any incentive payment made to me does not affect my benefits entitlement, my tax or national insurance position.