Application for membership of a Regional Advisory Committee for non-academics

This application form is for professionals who are not research active, such as commissioners and policy makers, to express an interest in becoming a member of an NIHR Research for Patient Benefit (RfPB) Regional Advisory Committee.

When a vacancy on a Regional Advisory Committee becomes available, your application will be considered. If no vacancy becomes available, your application form will be retained for two years. Please bear in mind that Regional Advisory Committees must have a balanced range of skills and expertise, and new members will be appointed as and when particular gaps emerge.

If you are a researcher or academic and would like to apply to join an RfPB committee, please use our alternative application form for researchers and academics.

More information on how to apply is available in the guidance for applicants to committee membership positions. Please email any queries to rfpb@nihr.ac.uk.

Applicant details

As this information will be used in official correspondence, please omit middle names and initials unless you need these to be used.

Title (required)

Surname (required)

Forename (required)

Contact details

Organisation (required)

Street (required)

Town/city (required)

County (required)

Postcode (required)

Telephone (required)

Extension

Mobile

Email Address (required)

Please note that if you are appointed as a member you will need to have access to a confidential email account

Professional details and areas of expertise

Please list roles relevant to this application.

Your current/last job title

Current/last employing organisation

Please give employment dates and responsibilities of role

Please give job title, employing organisation, employment dates and responsibilities for previous roles

Qualifications, relevant training and professional body accreditation

Please detail all relevant academic qualifications, training and professional body accreditation, outlining date, awarding body, and qualification obtained or training attended

Relevant experience

Please provide the details of experience you would offer to a Regional Advisory Committee.

List key areas of scientific, clinical, social care or health policy expertise/experience

Highlight relevant skills and relevant practical experience e.g serving on committees, advisory bodies, work within social care organisations or commissioners etc.

Provide details on commissioning experience

List research grants held or relevant publications

Evidence user experience (or carer experience in the case of social care)

Supporting information

Please explain why you are interested in becoming a Regional Advisory Committee member, and how your experience to date would help you to perform this role (Maximum 2,500 characters).

Supporting statement

Declaration of Interests

Please declare any personal, business or professional interests that have potential to conflict with the purpose, role or remit of an RAC. The purpose of this declaration is to ensure that the functions of the RAC can be exercised free of bias that could affect their independence in reaching decisions, and to ensure public confidence in the independence of the RAC. Please review NIHR Conflict of Interest Policy ahead of completing this section.

Please select (required)

I have no interests to declare
I wish to declare the following interests

I wish to declare the following interests

Declaration

By submitting this form I hereby declare that the information given in my application is correct to the best of my knowledge. I understand that falsification of information contained on this form may result in my appointment being terminated.

Please note that the details provided in this application form are covered by the NIHR Privacy Policy.

By completing this form you are agreeing to your details being added to our database. Your personal information is held and used in compliance with the General Data Protection Regulation 2016 (GDPR) and the Data Protection Act (2018). The Department of Health and Social Care, NIHR is the Data Controller under GDPR. Under GDPR, 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 DHSC NIHR bodies for the purposes of statistical analysis and other DHSC NIHR management purposes. We also reserve the right to share details of research applications with other approved research funding organisations outside the NIHR in order to coordinate research activity in the UK. Information collected from you will not be passed to any third party outside the NIHR except specifically as detailed above without your consent except where we are under a statutory obligation or entitled to do so by law. Applicants may be assured that DHSC NIHR is committed to protecting privacy and to processing all personal information in a manner that meets the requirements of GDPR. You can ask for your details to be removed from our database at any time.

If you require any further information or assistance, please send a brief description of your requirement to rfpb@nihr.ac.uk. Alternatively you can contact the RfPB Programme Management team at 020 8843 8057.

I have read and understood the data protection statement (required)