Expression of Interest for Service Users and Carers to join the Pharmacy Personal & Public Advisory Group - Page 1 of 4 - NI Direct

1. What is your name?

What is your full name? (Required)

Title (for example Mr, Mrs, Ms, Miss):

What is your preferred name:

5. Please select the option that best applies to you. Definitions are supplied in the Information Pack. I am currently a:

(Required) Service user representative Carer representative

6. Would you require support or reasonable adjustments to enable you to carry out this role?

(Required) Yes No

If Yes, please explain

7. Do you have access to and the ability to use telephone, email and the internet to communicate and take part in training, meetings and receive information?

(Required) Yes No

If no, please explain

8. Are you able to commit to the time commitment outlined for this opportunity?

(Required) Yes No

Please advise of any limits on availability:

All members will be asked to declare any Conflicts of Interest before each meeting. A conflict of interest occurs when an individual's personal interests – family, friendships, financial, or social factors – could compromise his or her judgment, decisions, or actions as a member of the advisory group.

9. Skills and Experience – please ensure you have read the skills and experience required for this role as specified in the information pack.

Please tell us why you decided to apply for this role? (maximum of 250 words)

(Required)

Please tell us about any other experience or skills you have which would support your application. You should refer to the required skills and experience outlined in the information pack. (maximum of 250 words) (Required)

10. How did you find out about this opportunity?

(Required) PCC newsletter HSC website Social media Word of mouth Engage (PHA) Community/Voluntary group Other

If other, please explain

You are now at the end of the Expression of Interest Form. Please ensure you have made all necessary amendments before proceeding.