Expression of Interest – Primary Care Chairing Impactful, Inclusive and Productive Meetings Workshop Terms and Conditions* Yes No (Form will not be accepted) By completing and submitting this form: I hereby give SELA consent to keep a record of my name, job role, organisation, band (if applicable), telephone number and email address on their secure contacts database for management information and communication purposes. Please see our Privacy Notice. You can opt-out of these arrangements at any point by contacting us at [email protected].Contact DetailsFirst Name* Surname* E-mail Address* Contact Phone Number* Please state what NHS Region you are from* East of England London North East and Yorkshire North West South East South West Midlands I do not know Other If you selected Other, please specify: Role / Job Title* What is your occupational group?Allied Health Professionals / Healthcare Scientists / Scientific and TechnicalMedical and DentalAmbulance (operational)Public Health (Public Health / Health Improvement)Commissioning (Commissioning managers / support staff)Registered Nurses and MidwivesNursing or Healthcare Assistants (Nursing auxiliary / Nursing assistant / Healthcare assistant (including Health / Clinical / Nursing Support Worker)Social CareWider Healthcare TeamGeneral Management (N.B. If you are a manager and can choose a group from elsewhere in the list, please select that other occupational group)Patient and Citizen LeaderAdministration & ClericalOtherWhat is your occupational group? (Ambulance/ operational)*Emergency Care PractitionerParamedicEmergency Care AssistantAmbulance TechnicianAmbulance Control Staff (e.g. call handler, dispatchers, PTS controllers)Patient Transport Service (e.g. ambulance drivers, support staff)What is your occupational group? (AHPs / Healthcare Scientists / Scientific and Technical)*Occupational TherapyPhysiotherapyRadiographyPharmacyClinical PsychologyPsychotherapyOperating Department PractitionerOther qualified Allied Health Professionals (e.g. dietetics, speech and language therapy)Support to Allied Health Professionals (e.g. support worker, therapy helper, therapy assistant or student)Other qualified Scientific and Technical or Healthcare Scientists (e.g. haematology, clinical biochemistry, microbiology)Support to healthcare scientists (e.g. technicians, assistants or students)What is your occupational Group/ (Registered Nurses and Midwives)*Adult / GeneralMental healthLearning disabilitiesChildrenMidwivesHealth VisitorsDistrict / CommunityOther Registered NursesWhat is your occupational group? (Social Care)*Approved social workers / Social workers / Residential social workersSocial care managersSocial care support staffWhat is your occupational group? (Wider Healthcare Team)*Admin & Clerical (including Medical Secretary)Central Functions / Corporate Services (e.g. HR, Finance, Information Systems, Information Technology)Maintenance / Ancillary (e.g. housekeeping, domestic staff, maintenance, facilities, estates)What is your occupational group? (Other, please specify)* Organisation*Ashford & St Peters Hospitals NHS Foundation TrustBerkshire Healthcare NHS Foundation TrustBerkshire West CCGBrighton & Hove CCGBrighton and Hove City CouncilBrighton and Sussex University Hospitals NHS TrustBuckinghamshire CCGBuckinghamshire Healthcare NHS Foundation TrustCentral Surrey HealthDartford and Gravesham NHS TrustEast Berkshire CCGEast Kent Hospitals University NHS Foundation TrustEast Sussex CCGEast Sussex County CouncilEast Sussex Healthcare NHS TrustFareham and Gosport CCGFirst Community Health and CareFrimley Park Health NHS Foundation TrustHampshire & Isle of Wight Partnership of CCGsHampshire Hospitals NHS Foundation TrustIndependentIntegrated care 24Isle of Wight CCGIsle of Wight NHS Foundation TrustKent & Medway NHS & Social Care Partnership TrustKent and Medway CCGKent Community Health NHS Foundation TrustKent County CouncilMaidstone & Tunbridge Wells NHS TrustMedway Community Healthcare CICMedway CouncilMedway NHS Foundation TrustNorth East Hampshire & Fareham CCGNorth Hampshire CCGOxford Health NHS Foundation TrustOxford University Hospitals NHS TrustOxfordshire CCGPortsmouth CCGPortsmouth Hospital NHS TrustQueen Victoria Hospital NHS Foundation TrustRoyal Berkshire NHS Foundation TrustRoyal Surrey County Hospital NHS Foundation TrustSolent NHS TrustSouth Central Ambulance Service NHS Foundation TrustSouth East Coast Ambulance Service NHS Foundation TrustSouth Eastern Hampshire CCGSouth, Central and West CSUSouthampton City CCGSouthern Health NHS Foundation TrustSurrey & Borders Partnership NHS Foundation TrustSurrey and Sussex Healthcare NHS TrustSurrey County CouncilSurrey Heartlands CCGSussex Community NHS Foundation TrustSussex Partnership NHS Foundation TrustUniversity Hospital Southampton NHS Foundation TrustWest Hampshire CCGWest Sussex CCGWest Sussex County CouncilWestern Sussex Hospitals NHS Foundation TrustOtherIf you selected 'Other' to the previous question, please specify. Please select the ICS your organisation is in*Buckinghamshire, Oxfordshire and Berkshire West ICSFrimley Health and Care ICSHampshire and Isle of Wight ICSSurrey Heartlands Health and Care Partnership ICSSussex Health and Care Partnership ICSKent and Medway ICSI do not knowOtherIf you selected 'Other' to the previous question, please specify. Do you work or is your primary role in the following area of care:* Primary Secondary Voluntary, community and social enterprise (VCSE) sector care I do not wish to disclose Unknown Do you have face-to-face contact with patients / service users are part of your day job?* Yes, frequently Yes, occasionally No For NHS and Social Care staff – please select your Agenda for change band*Band 1 – E.g. domestic support worker, housekeeping assistant, driver and nursery assistant.Band 2 – E.g. domestic support worker, housekeeping assistant, driver, nursery assistant, domestic team leader, security officer, secretary/typist and healthcare assistant.Band 3 – E.g. emergency care assistant, clinical coding officer, estates officer and occupational therapy worker.Band 4 – E.g. assistant practitioner, audio visual technician, pharmacy technician, dental nurse and theatre support worker.Band 5 – E.g. (includes many newly qualified clinical professionals) – operating department practitioner (ODP), podiatrist, learning disability nurse, therapeutic radiographer, practice manager and ICT test analystBand 6 – E.g. school nurse, experienced paramedic, health records officer, clinical psychology trainee and biomedical scientist.Band 7 – E.g. communications manager, estates manager, high intensity therapist and advanced speech and language therapist.Band 8a – E.g. consultant prosthetist/orthotist, dental laboratory manager, project and programme management, modern matron (nursing) and nurse consultant (mental health nursing).Band 8b – E.g. strategic management, head of education and training, clinical physiology service manager and head orthoptist.Band 8c – E.g. head of human resources, consultant clinical scientist (molecular genetics/cytogenetics) and consultant paramedic.Band 8d – E.g. consultant psychologist (8c-8d), estates manager, chief nurse and chief finance manager.Band 9 – E.g. podiatric consultant (surgery), chief finance manager and director of estates and facilities.VSMMedical/Clinical: E.g. Consultant, Doctor, Dentist, General Practitioner, Trainee Doctor, Academic DoctorApprenticeOtherI do not wish to discloseUnknownIf you selected Other, please specify:* Thinking about your motivations, please identify one objective which you hope to achieve in attending this programme*Are you Alumni of the NHS Graduate Management Training Scheme?* Yes No What was your intake year?* Specialism* General Management Finance Human Resources Health Analysis Health Informatics Policy and Strategy Management Would you be happy for us to contact you for further information?* Yes No