NIHR i4i Programme- Panel Membership Application Form
NIHR i4i Programme
Application Formto join i4i Panel
To express your interestin joining the NIHR i4i Programme panels, please complete this application form andprovide a full list of publications in Annex 1 (if appropriate).Please e-mail your completed form
For office use only
Date submitted:1. Applicant’s details
As this information will be used in official correspondence, please omit middle names and initials unless you would wish us to use them
Title*: / Please select ...ProfessorDrMrMsMrsMissOther / if other, please specify.…
Surname*:
Forename*:
Post held*:
Department*:
2. Contact details
Institution*:
Street*:
Town/City*:
County:
PostCode*:
e-mail address*:
Telephone*: / Extension:
Mobile:
NHS Trust Affiliation (if any):
3. Degrees and other qualifications*:
Please include the following information: Date; Qualification; Class; Subject; Awarding Body
4. Professional body accreditation:
Please give details of your accreditation with any professional bodies (including dates)
5. Present and previous positions held*:
Please include the following information: Dates; Job Title; Employing Authority
6. Research grants held:
Please include the following information: Dates; Title; Co-Applicants; Source (organisation name); Start date; Duration; Total grant
7. Research impact:
Please give examples of the impact of your research on patients and the NHS, and/or on applied health research more generally
8. Areas of experience, practice and interest*:
Please describe your experience, practice and interests relevant to this application (up to 2,000 characters)
9. Work on committees/panels and in an advisory capacity:
Please detail any relevant experience serving on committees, panels and/or advisory bodies (up to 1,500 characters)
10. Supporting statement*:
Please explain why you are interested in joining the NIHR i4i Programme as a panel member, and how your experience to date would help you to perform this role (up to 2,500 characters)
11. Announcement monitoring form*:
To help us plan future announcements, please let us know how you heard about the opportunity to apply to be a panel member of the i4i Programme:
NIHR websites (including NIHR CCF)
RDS websites
INVOLVE website
Direct e-mail
Through professional or personal networks
Other
Please provide further information
Please note that details provided in this application form are covered by NIHR CCF’s Privacy and Data Protection Statement .
Please provide a full list of publications in Annex 1 and e-mail your completed application form to .
If you require any further information or assistance please e-mail or call us on 020 8843 8015.
Annex 1. List of Publications:Please provide a full list of publications (if appropriate)
* field is mandatoryversion 4
January 2017
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