Annex B – JSNA Request Form

JSNA Topic Specific Needs Assessment Request Form

This form is to be completed by anyone requesting a topic specific needs assessment. The Population Health Hub (JSNA) Steering Group will review the form at the next monthly meeting, before any work commences.

What is a Health Needs Assessment (HNA)?

A HNA is a systematic approach to understanding the needs of a population. The assessment can be used as part of the commissioning process so that the most effective support for those in the greatest need can be planned and delivered. A health needs assessment provides an opportunity to improve outcomes where a population may be a group with a specific health need, demographic characteristic or geographical community. It is a holistic assessment considering social, economic, cultural and behavioural factors that influence health.

Topic title: Click or tap here to enter text.

Topic focus: Click or tap here to enter text.

Name of person requesting: Click or tap here to enter text.

Email address: Click or tap here to enter text.

Phone number: Click or tap here to enter text.

Please provide a brief summary of what is requested, and why (max 200 words):

Click or tap here to enter text.

Key stakeholders / contributors:

Click or tap here to enter text.

Data Requirements:

Click or tap here to enter text.

Public or patient engagement (is this required, is there an opportunity to do this, are there existing service user groups):

Click or tap here to enter text.

Reason for request (select all that apply):

☐ Part of commissioning cycle                     ☐ Service improvement

☐ To support a funding bid                           ☐ To launch/refresh a strategy

☐ Identified inequality                                    ☐ Board request

☐ Other (please detail) Click or tap here to enter text.

Type of output requested:

☐ Rapid (3-5 pages)                                       ☐ Detailed (5-20 pages)

☐ Other (please detail) Click or tap here to enter text.

Date required: Click or tap to enter a date.

Please save the competed form and return to healthandwellbeing@york.gov.uk or post to:

JSNA – Topic Specific Request
Public Health
City of York Council
West Offices
York
YO1 6GA