Service User and Carer Enquiry form

The School of Health & Life Sciences actively encourages the involvement of service users and carers in School activities with the aim of improving the learning experience of students and the care received by service users and carers. If you would like to be involved, please complete this form and we will be in touch. Please note this form is not compulsory but it will help us to monitor service user and carer involvement and progress your enquiry.

Please complete the below fields to submit this form

* Fields marked with an asterisk are required.

* Title

* Surname/Family name

* First name

* Gender

* Email

Phone

DOB (dd/mm/yyyy)

Are you (please tick one box only)

Do you have a condition or illness that you wish to disclose?

If yes, please outline brief details.

What experience of health and social care do you have that you would be willing to share?

If yes, please outline brief details

What activities would you like to be involved in?

Please tick one or more boxes to indicate your interests:

Teaching / classroom activity

Recruitment / selection (interviews) of students

Assessment of students

Course development / approval meetings

Focus groups

Research

Not sure yet

Do you have access requirements (for example wheelchair user / mobility issues etc)

Please outline brief details of your requirements.

The information you provide will be held by Teesside University in a secure and confidential database. The purpose of the database is to record contact details and to monitor service user and carer involvement. All personal information will be kept confidential and will be processed in accordance with the requirements of the Data Protection Act 1998 and the University's registration with the Information Commissioner. Your details can be removed at any time by contacting the Service User/Carer Involvement Co-ordinator on 01642 738798 or emailing XXXX@tees.ac.uk

I agree that my details can be kept securely, and understand they can be removed at my request.