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Transition into Integrated Care Systems – Action Learning Set

Transition into Integrated Care Systems – Action Learning Set

ALS Application Form

Step 1 of 6

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Application ID
Privacy Agreement
By completing this form you agree to our Privacy Policy. This includes using your personal data to contact you about the offer.*By completing this form you agree to our Privacy Policy. This includes using your personal data to contact you about the offer.
I agree to the Privacy Policy

Your Contact Details

Information: Why do we ask this?
Your contact details allow us to provide you with a response and connect you with a group facilitator.
Name*
First Last
Email*
Phone*

Your Work Details

Information: Why do we ask this?
Your work details allow us to group you with people from the same organisation, when relevant, and to monitor the reach of this offer.
Region*Which NHS region are you in?
STP*Which sustainability and transformation partnership do you work for?
Organisation*What is the official name of the primary organisation you work for?
Job Title*What is your main job title?

Learning Set Choice

Information: Why do we ask this?
These details help us allocate you to an appropriate action learning set.
Preferred ALS type*Please select which type of action learning you prefer

CCG Leaders
CCG Leaders focus

CCG leaders description to go here.

Reason for Applying

Information: Why do we ask this?
We will use your response to this question to prioritise the limited places available and determine the right group for your needs.
Reason*Please explain why would you like to focus on an Action Learning Set at this moment in time and why you have chosen the type of set you selected on the previous page. You should not disclose any personally identifiable data in this response.

Protected Characteristics

Information: Why do we ask this?

We use this information to ensure learning sets have a diverse membership and to monitor our inclusive access.
What is your approximate age?*
Do you consider yourself to have a disability?*

Yes

No

I do not wish to disclose
Disability categories*Please identify the category or categories that apply to you, or choose other type of disability.
Learning disability/difficulty
Long-standing illness
Mental Health Condition
Not declared
Physical Impairment
Sensory Impairment
Other
Are you now or have you ever defined yourself as Trans?*

Yes

No

I do not wish to disclose
Which of the following best describes your ethnic background?*
Which of the following best describes your religion or belief system?*
Which of the following best describes your gender?*

Female

Male

Another gender

I do not wish to disclose
Which of the following best describes your sexual orientation?*
Nationality*Please choose the (primary) country you officially belong to.
Hidden
Learning Set
Hidden
Reason for not approving application

Transition into Integrated Care Systems – Action Learning Sets

Apply to join Virtual ALS

NB: This application form is specifically for the CCG leaders group only.

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