1 Start 2 Complete Details of person being referred First Name * Last Name * Birth Date * Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Year Home address * City * Post Code * Address and postcode at time of referral (if different from home address) Address (including ward if relevant) City Post Code Demographic information about the person being referred How would you describe yourself (gender)? * Woman Man Prefer not to say Other (please state) If you selected 'Other' gender, please describe here How would you describe your sexual orientation? * Bisexual Gay Heterosexual/Straight Lesbian Prefer not to say Other (please state) If you selected 'Other' sexual orientation, please describe here How would you describe your religion or belief? * No religion Agnostic Buddhist Christian (including all denominations) Hindu Humanist Jewish Muslim Sikh Prefer not to say Other (please state) If you selected 'Other' religion, please describe here How would you describe your ethnicity? * Asian or Asian British Bangladeshi Asian or Asian British Indian Asian or Asian British Pakistani Any other Asian or Asian British Background Black or Black British African Black or Black British Caribbean Any other Black or Black British Background Chinese Mixed White & Asian Mixed White & Black African Mixed White & Black Caribbean Other Mixed Background Other White Background White British White Irish Prefer not to say Other (please state) If you selected 'Other Ethnicity' please describe here. Are you or the person you are referring being discharged from hospital? * - Select -NoYes, this is a standard dischargeYes, this is a delayed dischargeYes, this person is subject to a ‘Discharge to Assess’Yes, this person is being discharged from a psychiatric bed under the Mental Health Act If any of the following apply to you, please tick the box Mental health Learning disability Sensory Stroke Autism Cancer Drug/ alcohol misuse Heart condition Elderly/ frail Other physical illness or disability Alzheimer's/ Dementia No long term health condition Are you or the person you are referring living with a disability…? Yes No I don't know If you picked Other disability, please describe here. Consent and Communication Who is the person whose NHS treatment is the subject of this complaint? * - Select -MyselfA child of young person that I am the parent or legal guardian ofA friend or family member who has given their consent for me to progress their complaintA friend or family member who has not given their consent for me to progress their complaintSomeone I am working with as a professional Please state your preferred method of communication Home phone number Can voicemails be left on the home number? Yes No Mobile number Can we Text? Yes No Can voicemails be left on the mobile number? Yes No Email Eligibility Please tick the below box to confirm that you are currently resident in Manchester. * Please note, Gaddum’s IHCA service is for people resident in Manchester regardless of where the NHS treatment was provided Yes No Please confirm that your complaint relates to treatment you received from the NHS Please note, we can only provide support for people who wish to make a complaint about NHS treatment. We cannot provide support for complaints relating to private healthcare, the Local Authority or other organisations. Yes No Details of the complaint What action has been taken in processing this complaint? No action Concerns have been raised informally with the provider (e.g. the hospital, GP or trust) A complaint has been issued formally A complaint has been issued formally and a response has been received A complaint has been issued formally and a final response has been received Per NHS regulations, if you have already received a final response, you will not be eligible to be supported by the Independent Health Complaints Advocacy service) What setting did this incident occur in? * - Select -Ambulance ServiceBlood TransfusionCardiologyChildren's (paediatrics) serviceCommunity Hospital ServiceDentistryEar Nose and ThroatElderly (geriatric service)General Medicine GPGeneral SurgeryGPGynaecology and ObstetricsHospital Acute Services A&EHospital Acute Services InpatientsHospital Acute Services OutpatientsIndependent providers of NHS careMaternity ServicesMental Health ServicesNot KnownOpthalmicOpticianOther (please specify)Other community ServicesPharmacyPhysiotherapySocial CareTrauma and OrthopaedicsWalk in Centres If you have selected 'other', please describe here. What date did the incident/ issue that has triggered your complaint occur? If this occurred over a period of time, please select the end date * Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year19721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072 Year When did you become aware of this incident/issue? If you are unsure of the exact date, please provide your best guess. * Day12345678910111213141516171819202122232425262728293031 Day MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Year19721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072 Year If your complaint is older than 12 months, please explain why you have been unable to make the complaint sooner A complaint must be made no later than 12 months after the date of the incident happening or the date in which the subject of the complaint came to the attention of the complainant. The NHS may make exceptions for extenuating circumstances such as bereavement or if you were unaware of the issue. Please provide us with information about your complaint. * What support you need What support do you need from the Independent Health Complaints Advocacy (IHCA) service? * Making sure I contact the right NHS organisation or department for my complaint Support with writing a letter or notes More information about the complaints process and how it works What outcomes do you want to achieve? Apology Explanation Appropriate Remedy Change in process or procedure Financial Redress Disciplinary action against staff Per the NHS regulations, this is unlikely to be something the IHCA service can help you with. Your IHCA will not be able to instigate any disciplinary procedures against a member of staff as this decision is made by the organisation. You may be able to contact General Medical Council (GMC), General Dental Council (GDC) l, Nursing & Midwifery Council (NMC) to raise your concern) If you are a professional referring an individual to our IHCA service, please provide your contact details below By completing this form you agree to Gaddum keeping this information stored on a secure electronic case recording system, computer, and paper filing system. You confirm you are providing this information and asking for this referral in the client’s best interests. You are confirming wherein the client has capacity to do so, you have sought consent for this referral. Referrer Name Referrer Designation/Role Referrer Organisation Referrer Telephone Referrer Email Submit