Screen Reader Mode Icon

Patient and Public Panel Sign Up Form

Thank you for your interest in our Patient and Public Panel. At present, we are not actively recruiting new PPP members as we have hit our membership target. If you would like to register your interest in our PPP membership, please complete the sign up form below and we will contact you when we can complete your sign up with us.

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.

Question Title

* 1. First name

Question Title

* 2. Last name

Question Title

* 3. Email address:

Question Title

* 4. Telephone number

Question Title

* 5. Date of birth (in format 00/00/0000)

Question Title

* 6. Which county do you live in?

Question Title

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

Question Title

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

Question Title

* 9. Are you currently employed with us at North West Ambulance Service?

Question Title

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

Question Title

* 11. What skills and experience could you bring to the panel?
Do you have a vested interest or lived experience in a certain area.

Question Title

* 12. What does confidentiality mean to you?

Question Title

* 13. 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.

Question Title

* 14. Age:

Question Title

* 15. What is your gender?

Question Title

* 16. 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.

Question Title

* 17. What is your ethnicity?

Question Title

* 18. What is your religion or belief?

Question Title

* 19. Where did you hear about the panel?

Question Title

* 20. Are you happy for your details to be added to our secure recruitment wait list, and for us to contact you once a space has become available to join our PPP?

Question Title

* 21. 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

0 of 21 answered
 

T