Please give us the details of two people who would be willing to be a referee for you. Referee 1 Referee 2 Name: Name: Organisation (if relevant): Organisation (if relevant): Address: Address: Telephone: Telephone: Email address: Email address: How do you know this referee? How do you know this referee? Rehabilitation of Offenders Act 1974 If you have previously been convicted of any offences, please give details below, unless the conviction can be in terms of the Rehabilitation of Offenders Act 1974. regarded as ‘spent’ If you have no convictions please write NONE. …………………………………………………………………………… Conditions of involvement at Lewisham CCG When you are present in any of the or grounds you must follow certain CCG’s buildings policies, including: Health and Safety Equality and Diversity policies Guidelines about using telephones, computers, internet and email. Confidentiality You will not have access to patient, volunteer of staff information. However, you must understand that if any personal information is inadvertently made available to you this must remain absolutely confidential and reported to the appropriate member of staff. If you discuss such information with anyone, we will not allow you to continue working with us. Breaking confidentiality may also result in someone taking civil action against you. DECLARATION I have read and understood the above statements. I agree to be involved in the Public Reference Group and agree to the conditions. I consent to the information given on the form being entered onto the Patient Engagement database. It is my responsibility to ensure that any incentive payment made to me does not affect my benefits entitlement, my tax or national insurance position.
Please give us the details of two people who would be willing to be a referee for you. Referee 1 Name: Organisation (if relevant): Address: Telephone: Email address: How do you know this referee? Referee 2 Name: Organisation (if relevant): Address: Telephone: Email address: How do you know this referee? Rehabilitation of Offenders Act 1974 If you have previously been convicted of any offences, please give details below, unless the conviction can be regarded as ‘spent’ in terms of the Rehabilitation of Offenders Act 1974. If you have no convictions please write NONE. …………………………………………………………………………… Conditions of involvement at Lewisham CCG When you are present in any of the CCG’s buildings or grounds you must follow certain policies, including: Health and Safety Equality and Diversity policies Guidelines about using telephones, computers, internet and email. Confidentiality You will not have access to patient, volunteer of staff information. However, you must understand that if any personal information is inadvertently made available to you this must remain absolutely confidential and reported to the appropriate member of staff. If you discuss such information with anyone, we will not allow you to continue working with us. Breaking confidentiality may also result in someone taking civil action against you. DECLARATION I have read and understood the above statements. I agree to be involved in the Public Reference Group and agree to the conditions. I consent to the information given on the form being entered onto the Patient Engagement database. It is my responsibility to ensure that any incentive payment made to me does not affect my benefits entitlement, my tax or national insurance position.
PRG%20-%20Application%20form%202018.docx