Advisory Group Member Application Form
Panel or Board Member
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each box to enter text where applicable.
1. Area/s of expertise
Please tick all that apply:
Applied health research
Hospital physician
Public health
Chairperson
Occupational therapist
Radiologist
Child health:
Palliative care
Respiratory medicine
Primary care:
Rheumatologist
consultant paediatrician
consultant in public child
health
clinician expert in
midwifery
Clinician
general practitioner
other role
Psychiatrists & Nurse:
Senior NHS Manager
Director of NHS Trust
other role
Clinical pharmacologist
child psychiatrist
Statistician
Communicable diseases
and GU medicine
Consultant microbiologist
learning development
psychiatrist
liaison psychiatrist
Surgeon:
Consultant oncologist
neuro-psychiatrist
Gastroenterology
nurse
Health economist
old age psychiatrist
gastrointestinal
other surgeon
Wound care
2: Optional question
If you have an interest in applying to join a particular panel or board please outline this here.
(Maximum 250 words)
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3. Contact details
Title
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Other
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First name
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Middle name(s)
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Surname
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Suffix
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Organisation
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Other
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Address
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Town / City
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Postcode
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County
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Country
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Email address
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Telephone
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Web address
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Primary (work) address
Job position
Department
/ School
Type of
Affiliation
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Other affiliated organisations and contact details
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4: Professional details
Summary
Please summarise your knowledge, skills and experience using up to five 'key words' (such as
service management, smoking cessation, statistics, questionnaire design, health education etc.) in
the spaces below. The words you provide should summarise your content and knowledge as well as
any relevant research methods.
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Professional details continued
Research methodology skills
If applicable, please list the research methodology skills you have reached a strong level of
competency in. (Maximum 100 words)
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5: Knowledge
Please detail your specialist knowledge and how this demonstrates your suitability for an advisory
group member role, referring to the criteria in the person specification. (Maximum 250 words)
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6: Skills
Please detail your specialist skills to date and how they demonstrate your suitability for an advisory
group member role. (Maximum 250 words)
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7: Experience
Please explain why you are interested in becoming an advisory group member, and how you
anticipate your experience will help you to perform this role, referring to the criteria in the person
specification. (Maximum 250 Words)
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8: Getting involved
By completing this form you will automatically be entered into our external reviewer pool, who we
contact where appropriate to provide reviews on the content of short briefing papers, proposals for
research, and final reports of research findings.
To be removed from this pool please tick here
9: Please tell us how you heard about our advisory group member opportunities
How did you hear about getting involved as an advisory group member?
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Please submit your completed form, along with your CV and publications list (where applicable) by
emailing it as an attachment to AGmembers@soton.ac.uk. The body of your email message should
identify you so that we can contact you in the event of any problems.
If you have any queries please do not hesitate to contact us:
Tel. Number: +44 (0)23 8059 5586
Email Address: AGmembers@soton.ac.uk
Your personal information is held and used in compliance with the Data Protection Act 1998. The
Department of Health, National Institute for Health Research (DH NIHR) is the Data Controller under
the Data Protection Act 1998 ('the Act'). Under the Data Protection Act, 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 DH NIHR bodies for the purposes of statistical analysis and other DH NIHR
management purposes. Applicants may be assured that DH NIHR is committed to protecting privacy
and to processing all personal information in a manner that meets the requirements of the Act. We
will not pass your details to any third party or government department unless you give us permission.
You can ask for your details to be removed from our database at any time.
We publish an annual list of reviewers who have completed a review for us during the past year.
Your contribution as a reviewer will be acknowledged on our website as a gesture of our
appreciation. We will list your name and institution, and ensure that there is no indication of the
reviewing task that you completed. If you would prefer us not to publish your details, please indicate
so by ticking here