National Advisory Group on Clinical Audit and Enquiries - Member AD12-10

Application form

Thank you for your interest in this appointment.  This form can be completed on your own PC, and returned to appointments.team@dh.gsi.gov.uk with the above reference in the subject field in your email. If you are completing by hand, please use black ink to assist with photocopying.  This form should be returned, together with Annex A to the Department of Health Appointments Team with your CV and any continuation sheets.

The Department of Health is committed to ensuring that all appointments are made in a way that is open and fair to all applicants and all appointments are made on merit.

Your personal details

Surname		
First name		
Title				
Honours				
		
Home address

County		
Postcode		
Home contacts	Home Phone	Mobile	
	Fax No	Email	

Preferred e-mail address

Specific Expertise

This information pack provides details of the criteria sought for the Member post. 

This section gives you the opportunity to provide evidence to support how you meet all of the relevant criteria identified based on your professional/personal experience. 

Essential: Please demonstrate evidence of your proven record of achievement in managing and/or facilitating clinical audit locally at Trust-level. 	

	
Essential: Please provide evidence of your experience of working on a committee at a strategic level. 	

	
Essential: Please provide evidence of your strong commitment to improving healthcare and a clear understanding of the issues relating to clinical audit.	

	
Essential: Please demonstrate a strong commitment to improving clinical audit to enable it to fulfil its potential as a tool to stimulate improvements to clinical practice, enhance information for patients, and to support a range of other activities including medical revalidation.	

	
Essential: Please provide evidence of your ability to understand complex issues and balance a wide range of different stakeholder views.	

	
Essential:  Please provide evidence of your excellent personal communication skills.	

	

Your CV

Please enclose a brief, up to date CV (no more than 2 sides of A4) outlining your employment history, any relevant voluntary work, public service or other experience, together with any relevant professional, academic or vocational qualification. 

Ensuring public confidence

If you wish to declare anything about your professional or personal history, and/or if you have received a prison sentence or suspended sentence of 3 months or more within the last 5 years, which, if brought into the public domain, you believe may cause embarrassment or bring disrepute to NAGCAE, please provide details below including dates.

Failure to disclose such information could result in an appointment being terminated.

	

Declaration of interests

Do you have any business or personal interests that might be relevant to the work of NAGCAE and which could lead to a real or perceived conflict of interest were you to be appointed?  If yes, please provide details below.

Failure to disclose such information could result in an appointment being terminated.   

	

References

Please provide details of two referees who will support your application, at least one of whom must be from a “line management capacity” related to your most recent professional and / or voluntary activity. If you are invited to interview we may contact them at this stage. 

Name	
		Name		
Address			Address		
Postcode			Postcode		
Home Phone			Home Phone		
Mobile			Mobile		
E-mail			E-mail		
Relationship	
		Relationship		

How you found out about this post

To help us target our recruitment activity effectively and publicise posts in the future, it would be helpful if you could let us know how you found out about the vacancy. Please provide details below.

Declaration

To the best of my knowledge and belief, the information given in this form is complete and correct. I have considered and understood any criteria for disqualification from appointment and I am not disqualified. I understand that if I am appointed and any of the information I have provided is subsequently found to be untrue then my appointment may be terminated. I confirm and accept these conditions.

No			Yes		

	Signature
			Date