Patient, carer or advocate member: NICE guideline on the
diagnosis and management of attention deficit
hyperactivity disorder (ADHD) in children, young people
and adults
Application Form
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Section 1: Contact Information
Name:
Address:
Tel:
Email:
Please let us know how you came across this advert (please check one)
☐
NICE website
☐
Via patient, community or service user organisation - please state which:
☐
Social media - please state which:
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Email from NICE
☐
Other - please state:
NICE lay/community member application form 2015
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Section 2: Personal Experience and Knowledge
Please refer to the criteria in the Role Description and Person Specification for this role when
responding to this section. Not all of the questions in Section 2 may be applicable to you, as
your responses will depend on whether you are a patient, service user, relative, carer or
volunteer/employee of a relevant organisation or group. Please indicate if a question is not
applicable.
1. Please describe any personal experience you have of ADHD which you consider
relevant to this role and the areas of the guideline to be updated, as well as
indicating whether you are an adult or young person with ADHD:
2. Please describe any experience you have as a relative or unpaid carer of someone
who has ADHD which you consider relevant to this role and the areas of the
guideline to be updated:
3. Please describe any experience you have as a volunteer or employee of a relevant
patient, service user, carer, community or voluntary organisation, or support group,
which you consider relevant to this role and the areas of the guideline to be updated:
4. Please describe how your knowledge of the experiences and needs of a wide range
of people gives you the ability to champion patient or carer perspectives on this
topic:
Section 3: Other Experience, Skills and Abilities
Expressing views and participating in groups
5. Please give examples of your experience of participating in committees or groups
involving people from different social care, public health or healthcare professions
(known as multidisciplinary groups). Please include specific examples of any
committees or groups that you are or have been a member of:
Communication and team working
6. Please give examples of your communication and team-working skills that would be
relevant for working with a NICE committee (examples do not need to be health or
NICE lay/community member application form 2015
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social care related):
Research
7. Please give examples of any familiarity you have with research methods:
Equality
8. Please give examples of how you demonstrate an understanding of issues relating
to equality in relation to this topic. (Equality may be related to age, disability, gender
reassignment, marriage and civil partnership, pregnancy and maternity, race,
religion or belief, sex, sexual orientation, or socio-economic status):
9. Are you willing to commit to work within the NICE equality scheme?
Yes
☐
No ☐
Computer skills and experience
10. Are you able to use word processing (e.g. Word) and the internet?
Yes
☐
No ☐
11. Are you willing and able to communicate by email?
Yes
☐
No ☐
Time and commitment
12. Do you have the time to commit to the work of the committee? Please see the Role
Description and Person Specification for details of the time commitment. This
includes attending meetings, reading papers, commenting on draft documents, and
other work as required.
Yes
☐
No ☐
SECTION 4: Other information
13. Do you have a professional healthcare, social care or public health background?
Yes ☐
No ☐
If yes, please give details:
NICE lay/community member application form 2015
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(Note: Lay, community, service user or carer members are not expected to have this
kind of background – see role description and person specification for further
explanation.)
Additional information
14. If you wish, please provide brief details of other skills, knowledge or experience or
any other information which is relevant to your application that you have not already
covered:
References
Please give us the name and contact details of 2 people who can act as referees for
you. Your referees will not be approached unless you are invited to be a lay or
community member. The people you nominate as referees must:

Not be closely related by birth or marriage, or be in a relationship with or living
at the same address as you

Be able to comment on your suitability as a lay or community committee
member
If you have previously worked on a NICE committee please include your committee chair
as one of your referees.
Referee 1
Name:
Relationship to you:
Address:
Phone:
Preferred method of contact:
Email:
Email ☐
Phone ☐
Post ☐
Referee 2
Name:
Relationship to you:
Address:
Phone:
Preferred method of contact:
Email:
Email ☐
Phone ☐
Post ☐
Please return the following completed forms, by 5pm on Friday 5 February 2016:
NICE lay/community member application form 2015
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
This Application Form

Declaration of Interests form

Equality monitoring form
By e-mail: piprecruitment@nice.org.uk
By post: Public Involvement Programme Recruitment, NICE, Level 1A, City Tower,
Piccadilly Plaza, Manchester, M1 4BT
Data Protection
The personal data on this form and any other personal information which you send to the
National Institute for Health and Care Excellence will be held on the Institute’s files in
accordance with the Data Protection Act 1998. The personal data on this form will only be
used for the purpose of applying for membership of this committee. It will be passed to the
NICE team or collaborating centre running this committee and they will make the final
selection.
NICE lay/community member application form 2015
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