Health Involvement Network

1. Health Involvement Network

 
West Hampshire Clinical Commissioning Group (CCG) is the NHS organisation responsible for planning and buying health services locally. 

We have a growing group of people and organisations that are helping us make sure health services are right for everyone living in west Hampshire.

Please answer the following questions so we can let you know about the topics that most interest you.

By signing up to our Health Involvement Network you are agreeing that we may send you newsletters and emails with health related information you may be interested in. We may also ask if you would like to take part in surveys and focus groups occasionally, you are under no obligation to take part in either.

We will not pass any of the contact details you share with us to a third party.

1. Your name *

 

2. Your postcode *

 

3. Your email address *

 

4. How would you prefer us to contact you?

 

5. Your address

 

6. Your telephone number

 

7. If you represent a charity, voluntary or other organisation, please share the name of your organisation and your job title below

 

8. How involved do you want to be? You can choose one option or both.

 

9. Which health topics would you like to hear about or get involved in?
Please tick all those you are interested in.

 

10. Do you have any special needs we should know about so you can get involved?

 

11. I need communication support at meetings and events

YesNo
Hearing induction loop
Lip reader
Sign language interpreter
Advocate
 

12. I need written information in another language. Please specify

 

13. I need a language interpreter, please specify language

 

14. About you

I am a

 

15. Your gender

 

16. Your age group

 

17. Your ethnicity

 

18. Do you consider yourself to have a disability?

 

19. If yes, please tell us what your disability is

 

20. Are you a carer?

 

21. Your religion or belief

 

22. You would describe your sexuality as