Sign-up to the HSE Dublin and North East Partnership Network

If you have any questions or would like support filling in this form, please don't hesitate to get in touch with us. You can email us at Partnership.DublinNorthEast@hse.ie.

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Data privacy statement – How we use your information

The information you share in this form will be used by HSE Dublin and North East to support matching you with future partnership activities.

We collect this data to:

understand your background and interests
ensure diverse and inclusive representation
contact you about future partnership activities

Your information will be stored securely and will be restricted to HSE staff who require access to your data in managing this process. All data will be processed in line with General Data Protection Regulations (GDPR), the Data Protection Act 2018 and HSE Data Protection Policies.

The HSE’s Privacy Notice, which is on the HSE website will provide you with further information on how we process personal data as well as information on your rights as a data subject and how you can exercise those rights. Here is the link: HSE Privacy Notice Service Users V1.5

You can request for us to delete your personal data at any time by contacting us at Partnership.DublinNorthEast@hse.ie.

If you are not satisfied with how HSE is processing your data, you can contact the HSE Data Protection Office, contact details are available here: Data Protection Officer and Deputy Data Protection Officer contact details - HSE.ie. You also have a right to lodge a complaint with the Data Protection Commission (DPC). Contact details for the DPC are available at www.DataProtection.ie.

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Contact details

In this section, we ask you to share your contact details so we can get in touch about future opportunities.

1. First name *

2. Last name *

3. Email address *

4. Phone number *

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About you

In this section, we ask you some questions about yourself. This will help us with equality, diversity and inclusion monitoring and making sure we are involving people of different ages, ethnicities and backgrounds.

These questions are optional - you do not have to answer if you don't want to.

8. How would you describe your gender?

Male
Female
Non-binary
Other (please specify):

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Your involvement

In this section we will ask you about how you would like to get involved. This will help us tailor our involvement opportunities to suit your interests, needs and preferences.

10. Which description best describes your experience of health or social care services?

You are a patient or service user
You are a carer or support someone close to you
You work or volunteer with an organisation or group supporting people with lived experience
You work or volunteer with an organisation or group supporting underserved communities
Other (please specify):

11. Why would like to get involved in partnership activities in HSE Dublin and North East?

12. What types of topics would you be interested in getting involved with? For example, disability services, children's services, hospital services.

13. What skills or experience do you have that you would like to contribute? This might be from your personal life, paid or voluntary work, or training.

14. Do you need any support to take part in activities?

For example, this could be meeting at wheelchair accessible venues or getting information in large print.

15. Would you like to receive future partnership communications from HSE Dublin and North East?

These are not developed yet, but in the future may involve an email newsletter with updates and partnership opportunities. *

Yes, I would like to receive future partnership communications from HSE Dublin and North East
No, I do not want to receive future partnership communications from HSE Dublin and North East

16. Declaration and submission *

I confirm the information I have provided is accurate and I am signing up voluntarily

1. First name *

2. Last name *

3. Email address *

4. Phone number *

5. How do you prefer to be contacted? *

6. Where are you based?

7. What age are you?

8. How would you describe your gender?

9. What is your ethnicity or cultural background?

10. Which description best describes your experience of health or social care services?

11. Why would like to get involved in partnership activities in HSE Dublin and North East?

12. What types of topics would you be interested in getting involved with? For example, disability services, children's services, hospital services.

13. What skills or experience do you have that you would like to contribute? This might be from your personal life, paid or voluntary work, or training.

14. Do you need any support to take part in activities? For example, this could be meeting at wheelchair accessible venues or getting information in large print.

15. Would you like to receive future partnership communications from HSE Dublin and North East? These are not developed yet, but in the future may involve an email newsletter with updates and partnership opportunities. *

16. Declaration and submission *

14. Do you need any support to take part in activities?

For example, this could be meeting at wheelchair accessible venues or getting information in large print.

15. Would you like to receive future partnership communications from HSE Dublin and North East?

These are not developed yet, but in the future may involve an email newsletter with updates and partnership opportunities. *