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. 

Name

Question Title

* Name

Email

Question Title

* Email

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

Question Title

* 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.
Age

Question Title

* Age

Sex

Question Title

* Sex

Please select the option which best describes your sexuality

Question Title

* Please select the option which best describes your sexuality

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

Question Title

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

Marital  status

Question Title

* Marital  status

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

Question Title

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

Race

Question Title

* Race

White

Question Title

* White

Asian or Asian British

Question Title

* Asian or Asian British

Black/African/Caribbean/ or Black British

Question Title

* Black/African/Caribbean/ or Black British

Mixed/Multiple Ethnicity

Question Title

* Mixed/Multiple Ethnicity

Other Ethnic Group

Question Title

* Other Ethnic Group

Please indicate your religion or belief

Question Title

* Please indicate your religion or belief

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]

Question Title

* 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]

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.

Question Title

* 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.

T