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Expert by experience application form

Thank you for expressing an interest in working with us as an expert by experience. You may bring “lived-experience” of using NHS services, caring for someone in this situation or identify with a particular group or community. You may bring lived-experience of living with a condition or impairment, of experiencing physical or mental health issues, or a combination.

Please complete the application form below, which will be sent directly to the Patient Engagement and Involvement Team at Somerset Foundation Trust. Your application will be processed and a member of the appointing team will aim to be in contact with you within 2 weeks of receiving your application.

If you have any questions please contact the Patient Engagement and Involvement Team via email: myvoice@somersetft.nhs.uk.

Expert by Experience Application Form

First Name

Surname/Family Name

Please fill in your address details below


Address line 1
Address line 2
Town
County
Postcode

Please state your date of birth

Please fill in all your contact details below (please note each box will need to be filled in, if you don't have one of the options please write N/A)


Home Telephone
Mobile Telephone
Email Address

If you are under 18, you will need parental/carer consent in order to be an Expert by Experience at Somerset NHS Foundation Trust. Please give details below.


Name
Email
Telephone

The information in this form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal.

I agree to the above declaration

To see a copy of our privacy statement, and what we do with your data please go to Privacy and fair collection policy - About Us (somersetft.nhs.uk) or email myvoice@Somersetft.nhs.uk for a printed copy.

The Equality Act 2010 protects people against discrimination on the grounds of their age, sex, marital status, sexual orientation, national origin, race which includes colour, nationality, ethnic or national origin and any disabilities. Please complete the questions below if you feel comfortable to.

Please state your gender

Do you consider yourself to have a disability

Please select the disabilities that apply to you

Check all that apply

Physical impairment
Sensory impairment
Mental health condition
Learning disability/difficulty
Long standing illness
Other
Would prefer not to say

Are you currently bound over or do you have any current 'unspent' convictions or cautions (including reprimands or warnings) that have been issued by a Court or Court-Martial in the United Kingdom or any other country?

If yes, please include details of the order binding you over and/or the nature of the offence, the penalty, sentence or order of the Court, and the date and place of the Court hearing. You do not need to tell us about parking offences

Confidential information concerning patients and former patients

I declare that my attention has been drawn to the confidential nature of the information relating to the care and treatment of patients in the hospital.

I am aware that it is a condition of my placement that I shall not disclose any information concerning a patient or former patient to any person.

I confirm I have read the above and acknowledge the details

Patient Engagement media and social media consent form

I give consent to be photographed/filmed/interviewed

I understand that any photography or filming rights belong to Somerset NHS Foundation Trust.

I understand that I can withdraw my consent during photography or filming.

I understand that when photography or filming is complete, the rights of the image/s belong to Somerset NHS Foundation Trust and that I may not at a later point in time withdraw my consent for the film/photograph to be used for the purpose stated above.

I consent to the above declaration
I do not consent to the above declaration

If you are related to a director, or have a relationship with a director or employee of an appointing organisation, please state the relationship

How would you prefer to be involved?

Online Microsoft Teams Meetings
Face to Face Meetings

Expert by Experience Emergency Contact Details

Please fill in the below details regarding your emergency contact

Name
Mobile Number
Home Number
Address
Relationship to you

Please confirm you want to clear your response?