Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups are looking for partcipants from our local community to be involved in the Integrated urgent care recommissioning process and sit on the commissioning pannel.

More details and a specification outline can be found on the CCG Get Involved pages. 

If you have an interest in urgent care services and want to find out more about being involved, please complete the details below and we will be in touch with further information about the process and how you can help us to provide the right services for local people. 

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* Name

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* Email

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* Please provide us with the first part of your postcode (i.e. BS16, BS3 etc.)

The information you provide below will help us improve the health of the whole local population. To enable us to do this, please can you complete this monitoring form.  All the information you provide anonymous and confidential and will be held in accordance with the Data Protection Act.

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* Age

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* Sex

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* Please select the option which best describes your sexuality

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* Have you gone through a gender reassignment process or do you intend to?

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* Marital  status

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* Are you pregnant or have you given birth in the last 26 weeks?

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* Race

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* White

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* Asian or Asian British

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* Black/African/Caribbean/ or Black British

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* Mixed/Multiple Ethnicity

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* Other Ethnic Group

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* Please indicate your religion or belief

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* Do you consider yourself to have a disability?
[under the Equality Act 2010, a person is considered to have a disability if he or she has a physical or mental impairment and the impairment has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities]

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* It helps us to know whether we are reaching all people who have a disability. If you answered yes above, please can you tick the relevant disability group below and you are welcome to tick more than one box if applicable.

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