NCRI Consumer Membership Application to the Clinical Studies Groups

Please ensure that you complete all of the questions on this form

Personal Details

*Title

*First name:

*Last name:

*Address:

*City/town:

County:

*Postcode:

*Daytime telephone:

Mobile:

*Email:

*Q1. How did you find out about this opportunity?


NCRI Website (www.ncri.org.uk)INVOLVEOther Consumer/patientPeople in Research (www.peopleinresearch.org)Association of Medical Research CharitiesHealthcare/research professionalOther


If "Other" please specify below:


*Q2. Please indicate your current employment status:


CarerFull-time employmentPart-time employmentSelf-employedUnemployedHousewife/husbandStudentRetiredLong-term sick leaveVolunteerOther


If "Other" please specify below:


*Q3. Please indicate which NCRI Clinical Studies Group (CSG) you are most interested in joining (select all that apply):


Bladder & Renal Cancer CSGBrain Tumour CSGBreast Cancer CSGLung Cancer CSGPsychosocial Oncology and Survivorship CSGSarcoma CSGUpper Gastrointestinal CSG


Please specify your order of preference, staring with your first choice:


*Q4. Please explain your interest in cancer research and your reasons for wanting to work with the NCRI and the particular Clinical Studies Group (CSG) that you have indicated (300 words maximum):


*Q5. Having read the enclosed background information and role description please describe, giving examples, how your skills and experiences would enable you to fulfil the requirements of this role (300 words maximum):


*Q6. What would you hope to achieve as an NCRI consumer member, both in fulfilling the role itself and also in your own development? (300 words maximum):


*Q7. Having read the role description, please describe any training that you may require to support you in this role:


*Q8. Please give the name and contact details of two people, and the capacity in which you know them, that you are happy for us to contact for a reference. Preferably, someone who has known/worked with you in the past two years and is able to comment on your ability to undertake this role:

Reference 1 (all fields required)

Title

First name:

Last name:

Address:

City/town:

County:

Postcode:

Daytime telephone:

Mobile:

Email:

Capacity known:


Reference 2 (all fields required)

Title

First name:

Last name:

Address:

City/town:

County:

Postcode:

Daytime telephone:

Mobile:

Email:

Capacity known:

*Q9. Do you have any access needs of which we should be aware?


YesNo


If "yes" please specify:


*Q10. Any unspent criminal convictions will not necessarily exclude you from applying for this role, but will be taken into consideration when assessing your suitability.

Do you hold any unspent criminal convictions or have any pending court cases?
YesNo

*Q11. Click here to complete the NCRI Diversity Monitoring Questionnaire. This form must be completed before submitting your application.

If you have any enquiries in regards to this application please contact the NCRI Research Involvement Officer or call 0203 469 6121.


Declaration

I agree to the information provided on this form being used for legitimate purposes connected with recruitment and selection monitoring.

I declare that the information given is, to the best of my knowledge, true and complete.

I have completed the NCRI Diversity Monitoring Questionnaire (Q11)

As this application form will be submitted electronically, you do not need to sign it now however you will be asked to do so should you be invited to join an NCRI Clinical Studies Group.

I have read and understood this declaration.