ELR Shining Stars Online Form Step 1 of 6 16% Are you happy to give us your details or would you prefer to remain anonymous?* Yes, I am happy to give you my details I would prefer to remain anonymous Please tell us about youAddressName* Address Street Address City Postcode* Email* Phone Social MediaYour Twitter Account (including the @ symbol) Contacting youWhat is your preferred method for us contacting you?*By emailBy postI do not want to be contacted by youBy registering for a free myFed account, you can receive regular e-mail updates on latest news from the ELR GP Fed. Would you like us to create a myFed account for you for free?*Yes pleaseNo thanksPlease check that you've given us your postal address if you would like us to contact you by postPlease check that you've given us at least one social media account What is the name of your Shining Star?* First Last Role/Job Description Organisation/Employer (if applicable) Tell us why this person is your Shining Star*Are you happy for us to contact your Shining Star?* Yes No Please give us their contact details belowDoes your Shining Star work for or with one of our members? (that is a GP Practice in East Leicestershire and Rutland)?* Yes No I'd rather not say Are you happy for us to tell the Practice directly about your nomination?* Yes No Which GP Practice does your Shining Star work for or with Countesthorpe Health Centre County Practice Dr Kilpatrick and Partners Empingham Medical Centre Enderby Medical Centre Forest House Medical Centre Glenfield Surgery Hazelmere Medical Centre Kibworth Health Centre Kingsway Surgery Latham House Medical Practice Long Clawson Medical Practice Long Street Surgery Market Harborough Medical Centre Market Overton & Somerby Surgeries Narborough Health Centre Northfield Medical Centre Oakham Medical Practice Rosemead Drive Surgery Severn Surgery South Wigston Health Centre The Billesdon Surgery The Central Surgery The Croft Medical Centre The Husbands Bosworth Surgery The Jubilee Medical Practice The Limes Medical Centre The Masharani Practice The Uppingham Surgery The Wycliffe Medical Practice Wigston Central Surgery We may like to refer to your comments in public. Is this OK with you?* Yes, I am happy for you to refer to my comments in public and use my name Yes, I am happy for you to refer to my comments in public, but please do not use my name publicly No, I would prefer to keep my comments private between ourselves We would like to ask you some questions which will help with our equalities monitoring. You do not have to answer any of these questions if you would prefer not to and they will not affect how we treat your comments or ideas in any way, however it will help with our equalities monitoring if you are able to do so* Yes, I am happy to provide information to support your equalities monitoring No, I would prefer not to provide information to support your equalities monitoring Equalities MonitoringWhat is your gender? Male Female Do you consider yourself to be transgender? Yes No If you are transgender, what was your (assigned) gender status at birth? Female Male Third Choice Age GroupUnder 1616-2425-3435-3940-4950-5960-7576 or AboveWhat is your ethnicity?AfricanAsian or Asian BritishBangladeshiBritishCaribbeanChineseIndianIrishMixed/dual heritageOtherOther AsianOther WhitePakistaniWhiteWhite & AsianWhite and Black AfricanWhite and Black CaribbeanWhite BritishWhite ScandinavianPrefer not to sayDo you consider yourself to have a disability? If Yes, please give details Yes No Prefer not to say Details of your disability Do you consider yourself to be: Heterosexual or straight Gay or lesbian Bisexual Marital or Same Sex Civil Partnership Status single - that is never married and never registered in a same-sex civil partnership married separated but still legally married divorced widowed in a registered same-sex civil partnership separated but still legally in a same-sex civil partnership formerly in a same-sex civil partnership which is now legally dissolved surviving partner from a same-sex civil partnership Which of the following categories best describes your employment status? Employed - working full-time Employed - working part-time Not employed - looking for work Not employed - not looking for work Retired Disabled - not able to work self employed - sole trader self employed -small business owner in full time education in part time education or training in an apprenticeship Many thanks for giving us feedback. It is really appreciated. Δ
