Advisory Group Member Application Form

HS&DR Panel Chair

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1. Contact details
Title / Please choose an itemDrProfessorAssociate ProfessorEmeritus ProfessorHonorary ProfessorMissMrMrsMsSir / Other / Please choose an itemProfessor DameProfessor SirProfessor LordChiefDameJudgeBaronBaronessLadyLordMasterReverendReverend DoctorReverend ProfessorFatherDistrict JudgeSuperintendentDetective SuperintendentColonelCouncillorDr SirLt ColProfessor DrSister
First name / Please double click to enter text / Middle name(s) / Please double click to enter text
Surname / Please double click to enter text / Suffix / Please choose an itemOBEMBECBEKBEEsq.IIIIIJr.Sr.
Primary (work) address
Job position / Please double click to enter text
Department / School / Please double click to enter text / Organisation / Please double click to enter text
Type of Affiliation / Please choose an itemBoard MemberConsultantEmployeeMemberRepresentativeTrusteeVolunteerCouncillor / Other / Please double click to enter text
Address / Please double click to enter text / Town / City / Please double click to enter text
Postcode / Please double click to enter text / County / Please double click to enter text
Country / Please double click to enter text / Email address / Please double click to enter text
Telephone / Please double click to enter text / Web address / Please double click to enter text
Other affiliated organisations and contact details
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2: Professional details
Summary
Please summarise your knowledge, skills and experience using up to five 'key words' (such as service management, smoking cessation, statistics, questionnaire design, health education etc.) in the spaces below. The words you provide should summarise your content and knowledge as well as any relevant research methods.
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Professional details continued
Research methodology skills
If applicable, please list the research methodology skills you have reached a strong level of competency in. (Maximum 100 words)
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3: Knowledge
Please detail your specialist knowledge and how this demonstrates your suitability for an advisory group chair role, referring to the criteria in the person specification. (Maximum 250 words)
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4: Skills
Please detail your specialist skills to date and how they demonstrate your suitability for an advisory group chair role. (Maximum 250 words)
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5: Experience
Please explain why you are interested in becoming an advisory group chair, and how you anticipate your experience will help you to perform this role, referring to the criteria in the person specification. (Maximum 250 Words)
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6: Other information
Please outline any other information of relevance to this position. (Maximum 500 words)
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7: Getting involved
By completing this form you will automatically be entered into our external reviewer pool, who we contact where appropriate to provide reviews on the content of short briefing papers, proposals for research, and final reports of research findings.
To be removed from this pool please tick here
8: Please tell us how you heard about our advisory group member opportunities
How did you hear about getting involved as an advisory group member?
Please choose an itemBMJ onlineColleagueE-Bulletin (please specify)Email alertGuardian onlineHSJ onlineNIHR websiteOther websiteProgramme website
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Please submit your completed form, along with your CV and publications list (where applicable) by emailing it as an attachment to . The body of your email message should identify you so that we can contact you in the event of any problems.
If you have any queries please do not hesitate to contact us:
Tel. Number: +44 (0)23 8059 5586
Email Address:
Your personal information is held and used in compliance with the Data Protection Act 1998. The Department of Health, National Institute for Health Research (DH NIHR) is the Data Controller under the Data Protection Act 1998 ('the Act'). Under the Data Protection Act, we have a legal duty to protect any information we collect from you. You should be aware that information given to us might be shared with other DH NIHR bodies for the purposes of statistical analysis and other DH NIHR management purposes. Applicants may be assured that DH NIHR is committed to protecting privacy and to processing all personal information in a manner that meets the requirements of the Act. We will not pass your details to any third party or government department unless you give us permission. You can ask for your details to be removed from our database at any time.
We publish an annual list of reviewers who have completed a review for us during the past year. Your contribution as a reviewer will be acknowledged on our website as a gesture of our appreciation. We will list your name and institution, and ensure that there is no indication of the reviewing task that you completed. If you would prefer us not to publish your details, please indicate so by ticking here