Raise a Concern

Speaking up at work is really important. By speaking up you will be playing a significant role in helping us to keep improving our services for patients and the working environment for our people.

Please provide us with as much information as you can so that we can respond to you and any concerns you might have as quickly and efficiently as possible.

You can use this form to speak up anonymously and we will always do our best to fully investigate any issues raised. However, if you do not provide your contact details, we will not be able to keep you posted on progress and outcomes.

An asterisk ( ) indicates that a certain field is mandatory/required.

Your Personal Details

How would you like to raise your concern?

Confidentially

You are willing to give your name and contact details to the guardian, but you do not want your identity disclosed to anyone else without your consent.

Anonymously

You do not wish to give your name to the guardian. This can make it more difficult to investigate your concern thoroughly or give you feedback on the outcome.

Name

Job Title

Preferred Email Address

Telephone Number

Best Method of Contact

Why are we asking you these questions?

Airedale NHS Foundation Trust is committed to promoting equality and eliminating unlawful discrimination, and we are aiming to achieve diversity in the range of people we involve. You do not have to answer these questions, and we understand that some of this information is personal and sensitive in nature. However, we would like to keep track of who is speaking up to us. This will help us understand who is using the service and whether there are particular groups of staff experiencing barriers to speaking up.

This monitoring information will only be used for identifying trends and will never be reported in a way that could be linked back to you. For example, we might say that 80% of colleagues who contact us are female, or that 20% are from ethnic minority backgrounds.

If you would like any further information about how this data is stored or used, please contact the Freedom to Speak Up Guardian: anhsft.raisingconcerns@nhs.net.

Ethnicity

Age

Gender

Religion or belief

Sexual Orientation

Professional/Worker Group

For more information on why we require this data from you please see the national guardian guidance (opens in a new window).

Do you consider yourself to have a disability? This is defined as any physical or mental health conditions or illnesses lasting, or expected to last, 12 months or more.

Prefer Not To Say

Yes

Concern Details

Main Theme of Concern

Select the department/service the concern relates to

Have you or anyone else raised this concern through our AEF system (Adverse Event Form)

Yes

I Don't Know

Nature of Concern

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