Northern IAPTPractice Research Network
Membership application form

PURPOSE

This form is intended to gather information from network members in order to:

  • Confirm the list of member organisations and their named representatives
  • Gather information about the clinical data management systems used by partner IAPT services, so that this can inform the development of data-based studies
  • Confirm that member organisations have read and accepted the term of reference of the Northern IAPT PRN

1. Relevant details

Please fill in the relevant information in the below table. If you work for an academic institution, please only complete the relevant fields.

Name of your IAPT service and wider organisation
Contact details for the person(s) who will represent your service and will be a named member of the Northern IAPT PRN / (Name, email, telephone, postal address)
What clinical records system do you use to collect IAPT data?
Who is the IT / data lead in charge of reporting IAPT data to the Department of Health? / (Name, email, telephone, postal address)
Contact details for key contact person in your Research & Development Department / (Name, email, telephone, postal address)

1. Confirmation of agreement with terms of reference

The terms of reference (TOR) document describes the way in which the Northern IAPT PRN operates. This document was drafted based on a consultation with several services and Universities during 2014. You can access the TOR document here:

Your service / organisation will be included in the membership of the PRN subject to confirmation of agreement with the TOR document. Please add your service representative’s name and date below to confirm that you have read and communicated the TOR to your service management, and you therefore confirm agreement with these terms.

Service representative name:[Add name here]

Date:[date here]

Has your service agreed with TOR?YES / NO

NEXT STEPS

Please email your application form to:

Your application will be reviewed by the current Chairman of the network and you will receive a confirmation of membership via email, after which your service’s name will be added to the Website Home Page, and you will be included in the mailing list to link in with network updates and activities.