Patient/Carer Members of Guideline Development Groups

							C          Personal Statement to support application for community
                                                                                               Page 1 of 3

        membership of Smoking Cessation Programme Development Group
                                     To be completed by nominee.

Before completing the form, please read the nomination information sheet (A) which explains what this
work entails. Please use this form to provide information about the experiences, knowledge and skills you
could bring to the Programme Development Group. We don’t expect applicants to be experienced in
everything listed below. Please continue on a separate sheet if necessary.
NICE will use the information you provide to decide how to obtain the best spread of experience from all
members of the Programme Development Group and, on that basis, NICE will select individuals to join
the group.

To complete the form, please click the cursor in the designated box. The box will expand as you write.
To move from one box to another, you can use the tab key, the arrow keys or click in the next box.

1. NAME
2. DATE

3. EXPERIENCE OR KNOWLEDGE OF TRYING TO GIVE UP SMOKING (OR CHEWING
   TOBACCO) AND SUPPORT SERVICES

       Have you tried to give up smoking (or chewing tobacco) and received support to do this?

        Yes            No             If Yes, please explain what type of help or support you have had?
        (for example, help from a ‘stop smoking’ service; support in the workplace; use of self-help
        materials such as books, videos, internet; therapies such as hypnotherapy or acupuncture; events
        such as ‘No Smoking Day’)


       Are you, or have you been, the relative or carer of someone who has tried to give up smoking (or
        chewing tobacco)?

        Yes           No             If Yes, please briefly describe your experience




       Are you an active member of a relevant support group, community group, patient organisation,
        charity, voluntary or non-governmental organisation?
        Yes            No             If Yes, please state name of group




       Are you an employee of a relevant patient organisation, community organisation, charity,
        voluntary or non-governmental organisation?
        Yes            No            If Yes, please state name of group and job title




              Patient and Public Involvement Programme at NICE
                                                                                               Page 2 of 3
     Please describe briefly any personal experience or knowledge - of trying to stop smoking (or
      chewing tobacco) and the services and support that exist to help people quit - that you could bring
      to the guideline development group




     Do you have contacts with other people who have tried stopping smoking (or chewing tobacco) or
      have quit, whose experiences you could draw on to inform your contributions to the Programme
      Development Group?

      Yes            No             If Yes, please give brief details




     Please describe briefly any experience or knowledge you could bring to the Programme
      Development Group about issues for smokers from one or more social groups where smoking
      rates are high (or where there may be additional barriers to quitting). For example, manual
      working groups, pregnant smokers, young smokers, post-retirement smokers, people living on
      very low incomes, some minority ethnic groups, homeless people, people in prison, people with
      mental health or substance abuse problems.



4. MEMBERSHIP OF COMMITTEES OR GROUPS
     Please give examples of any committees or groups (health or non-health related) you have been a
      member of



     Please give examples of anything you have been involved in which demonstrates your ability to
      contribute to a multi-disciplinary group (a group involving people from different health
      professions)



5. RESEARCH
     Please give examples if you have done anything which demonstrates an interest in, or knowledge
      of, research related to health. (Research knowledge or experience is not an essential requirement.)



6. OTHER INFORMATION
     Will you have time to attend regular meetings (about 10 meetings over a period of about 12 -15
      months, possibly with one or two meetings held over two consecutive days) and do the necessary
      work in between (e.g. read papers)?    Yes            No

     Do you have a healthcare or professional public health background?      Yes           No

      (NB: Community members are not expected to have a healthcare or professional public health
      background – see nomination information sheet (A) for further explanation.)

            Patient and Public Involvement Programme at NICE
                                                                                               Page 3 of 3
          Are you employed in the tobacco industry or commercial health industry (such as pharmaceutical
           or other companies providing smoking cessation aids or services)? Yes              No

           If Yes, please give details

          Do you have any practical support needs (for example, would you need to bring a carer with you
           to meetings, do you use a hearing aid etc.)?
           Yes                   No                    If Yes, please say what these requirements are



          Rehabilitation of Offenders Act 1974. Please can you declare here any convictions, cautions or
           bind-overs, which are pending or current; or indicate ‘none’. (Please note that for the purposes of
           this nomination form, you do not have to declare spent convictions, and that even where you
           indicate a conviction, it will not necessarily disqualify you from membership of a Programme
           Development Group.)




          Please provide brief details of other relevant skills, knowledge or experience not described above




Please return this completed personal statement (Form C) along with the nomination
form (Form B) to the Patient and Public Involvement Programme at NICE (see Form B for
address details).
Data Protection
The personal data on this form and any other personal information which you send to the National Institute for Health and Clinical 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 nomination for
membership of the Programme Development Group.




                  Patient and Public Involvement Programme at NICE