NHS Evidence Accreditation External Adviser Application Form

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NHS Evidence Accreditation External Adviser Application Form Powered By Docstoc
					                               Accreditation External Adviser Application
Please complete all sections of this form and email together with Declaration of Interests form as
attachments to adviserapply@evidence.nhs.uk.

Alternatively, please print the completed forms and send to:

Maggie Derry, Project Manager
National Institute for Health and Clinical Excellence (NICE)
Level 1A | City Tower | Piccadilly Plaza | Manchester M1 4BD | United Kingdom

We look forward to hearing from you and would be happy to answer any questions which you might

Contact details

Full Name
(Including title, Dr, Prof, etc)
Job Title


(Full address, including postal/ZIP code)

Telephone number

Fax number

Email address

Mobile number
(where available)
Additional information
(eg Secretary/PA contact details)
Specialist area of interest – please identify your area of expertise and experience using the drop down list. Note that
we are seeking individuals with expertise in guidance. Guidance is defined as 'systematically developed statements to
guide decisions about appropriate health and social care to improve individual and population health and wellbeing.'
Please click to choose
Supporting statement to become an NHS Evidence accreditation external adviser – please describe your role(s)
and how your expertise and experience qualifies you as an external adviser. Relevant expertise can include guidance
methodology, development, implementation or evaluation in a clinical, commissioning, social care, public health, or
healthcare industry setting. Although not essential it is desirable that external advisers have contributed as an author to
three or more publications that are relevant to guidance.

The information you submit on this form will be used by the National Institute for Health and Clinical Excellence
(“NICE”) for developing the work of NHS Evidence. Names, job titles and the organisations represented by panel
members may be published on the NICE website or in NICE documents. The information may be kept on a NICE
database for the purpose of future reference, research and statistical analysis and will be held in accordance with the
Data Protection Act 1998. Equalities information will be held internally for monitoring purposes only and this will not be
disclosed to third parties.

By submitting your data to NICE you are agreeing to its use as set out above.
I have read and understood this statement.

Signed:                                                                Date:

     Please tick here if you are happy to be approached to provide advice or information to support other NICE
     programmes of work.

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