Leading a Culture of R&I in Primary Care across Lancashire and South Cumbria – Application Form
Applicant details
Title
Applicant Name
*
First Name
Last Name
Profession
*
Name of Employer/Organisation
*
Job Title
*
Salary Band ( we're asking this solely for backfill allocation purposes)
*
Group 1 – Salary: up to 40k pa (e.g. primary care nurses, PCN nurses): Backfill £25/hour
Group 2 – Salary: 40k to 70k pa (e.g. community pharmacists): Backfill £45/hour
Group 3 – Medical grade (e.g. GPs, Trainee GPs): Backfill £72.50/hour
Work Address
*
Postcode
*
Contact email
*
example@example.com
Contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Professional Registration Number (PIN number)
*
Date of professional registration
*
Support required as a consequence of any disability or medical condition
Application statement and attachments
Brief description of your current role
*
0/200
Please detail briefly why you wish to undertake the Leading a Culture of R&I in Primary Care programme and how will you benefit?
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0/300
Previous interest/involvement in research (you don't need any previous involvement in research to qualify)
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0/300
Attach your brief CV (This should be no more than 2 A4 pages and will include current educational attainment, professional qualifications/registration where appropriate, any prior research experiences including training to date, brief summary of any publications, grants, research presentations and other information applicants consider may be relevant to this application).
*
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Line manager support
Applicant’s name
*
Line manager name
*
First Name
Last Name
Manager Support Statement - Please provide a brief supporting statement from your line manager confirming their support for your participation in the programme. This could outline how the learning gained will be shared with the team and wider organisation, and how it will contribute to service delivery and organisational priorities. You may also include any specific themes or focus areas that would be beneficial for the applicant to explore.
*
0/100
Signature of line Manager
*
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Line manager contact telephone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Line manager contact email
*
example@example.com
Email sharing consent
I am happy for my email address to be shared amongst NHS R&D North West for future communications
*
Yes
Applicant declaration
I confirm the information is true, I can attend the required dates, and I consent to sharing my contact details with NHS R&D Networks
*
Yes
Applicant signature
*
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Equality and diversity monitoring
Age group
Please Select
18–25
26–35
36–45
46–55
56–65
66+
Prefer not to say
Are your day-to-day activities limited because of a health problem or disability (12+ months)?
Please Select
Yes, limited a little
Yes, limited a lot
No
Prefer not to say
Type of disability
Vision
Hearing
Mobility
Learning
Mental health
Stamina/breathing/fatigue
Social/behavioural
Other
Ethnic group
Please Select
White - Welsh/English/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Any other Asian background
Black or Black British - African
Black or Black British - Caribbean
Any other Black background
Other ethnic group
Prefer not to say
Any other White background
Any other mixed background
Any other Asian background
Any other Black background
Any other ethnic group
Gender
Please Select
Male
Female
Prefer not to say
Prefer to self-identify
Prefer to self-identify gender
Have you gone through or intend to go through any part of a process to align physical sex appearance or gender role with gender identity?
Please Select
Yes
No
Prefer not to say
Legal marital or civil partnership status
Please Select
Divorced
Formerly in a registered civil partnership which is now dissolved
In a registered civil partnership
Married
Never married and never registered a civil partnership
Separated (still legally married/in a civil partnership)
Surviving partner from a civil partnership
Widowed
Prefer not to say
Religion
Please Select
No religion
Atheist
Buddhist
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
Hindu
Jewish
Muslim
Sikh
Any other religion
Prefer not to say
Any other religion
Sexual orientation
Please Select
Heterosexual/straight
Lesbian
Gay
Bisexual
Prefer not to say
Prefer to self-identify
Prefer to self-identify sexual orientation
Do you look after or give any help or support to others because of long-term ill-health/disability or problems related to old age?
Please Select
No
Yes, 1–19 hours a week
Yes, 20–49 hours a week
Yes, 50 or more hours a week
Prefer not to say
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