Brownlee HIV

Who are you? Please tick the appropriate box to let us know who you are in relation to the incident.

Patient who experienced stigma or discrimination
Friend or relative of patient
NHSGGC staff member

Please write a short description of your experience: You can write about any NHSGGC services in the past 3 years. You may want to tell us about; What took place? Who was involved? How did you feel? What could have been better?

Name of Service: (Where the incident took place)

Venue/location of Service: (Where the incident took place)

Date the incident took place: It is ok if you don't remember exactly, an estimate is fine.

Did you make a formal complaint? Please tick one

YES
NO - Please complete contact details below if you would like the HIV Peer Support Manager to discuss the incident with you.

Please complete your contact details below if you wish the HIV Peer Support Manager to discuss the incident with you.

First name:

Surname:

Address line 1:

Address line 2:

Town / City:

Postcode:

Email:

Phone:

Have you already reported this as a Datix? Please tick one.

YES - If you are happy to share please tell us the Reference Number below.
NO - But would like to discuss. Complete the contact details and the HIV Peer Support Manager will contact you.

Reference number:

NHS Greater Glasgow and Clyde's HIV website

HIV Stigma or Discrimination Incident Form

Relevant Links