Patient & Public Involvement Committee Application Form

Patient and Public Involvement (PPI) Committee Application Form
Personal Information
Preferred title:
e.g. Mrs, Mr, Ms, Dr, etc)
Full Name:
Email
example@example.com
Location
Background Information
How much experience do you have of patient and public involvement?
Please tell us if you have been or are involved in the work of any other NIHR or prioritisation committee?

YesNo
If ‘Yes’ please give details
Please list up to 5 of your current or previous employment and voluntary positions that you feel are most relevant to the role of a PPI committee member. If you do not have sufficient employment or voluntary positions, please add relevant life experiences.
In line with the NIHR payment policy, we are obliged to ask if you are in receipt of a public sector salary. If your answer is “Yes”, you must confirm that the role you would like to undertake with NIHR is unrelated to your public sector role.

(Public Sector Definition: Any organisation run by the government and funded by tax-payers money can be classified as public sector, for example, local councils, NHS Hospitals)
Are you in receipt of a public sector salary?

YesNo
If you answered “yes” above, do you confirm that the role you propose to undertake with the NIHR is unrelated to your public sector role?

YesNot applicable
Experience and knowledge
How will your experience and knowledge benefit the Accelerated Surgical Care HealthTech Research Centre?
You can add details of any additional involvement in clinical/medical research
Your interest in the role
Tell us why you are applying for the role
Would you like to be considered for the HRC Executive Committee? This meets six weekly.

YesNoMaybeOther
Other
Do you have any accessibility or support requirements in order to be able to participate fully in this Committee?
Describe any support requirements that you may need here.
How did you hear about this opportunity?

FacebookTwitterLinkedInInstagramHRC WebsiteColleague or friendPeople in Research websiteMailing listOther
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Equality, Diversity and Inclusion (EDI)

NIHR welcomes applicants from all sections of the community and are committed to recruiting a diverse workforce which reflects the wider population. In addition to this, in adherence to the Equality Act (2010), our recruitment processes are fair and do not discriminate against or disadvantage anyone based on; age, disability, gender reassignment status, marriage or civil partnership status, pregnancy or maternity, race, religion or belief, sex and sexual orientation.
What will be your age range as at 31 December 2024?
How would you describe your gender?
If Other, please specify below:
Choose one option that best describes your ethnic group or background
Do you consider yourself to be a disabled person?
Are your day-to-day activities limited because of a health problem or disability which has lasted, or is expected to last, at least 12 months?

Yes, limited a lotYes, limited a littleNo
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Patient and Public Involvement (PPI) Committee Application Form

Personal Information

Background Information

Experience and knowledge

Your interest in the role

Other

Equality, Diversity and Inclusion (EDI)