Community Partners Panel If you would like the opportunity to join our Community Partners Panel please complete and submit the Expression of Interest Form below: Community Partners Name* First Name Last Name Address Street Address Address Line 2 City State / Province / Region Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail* Please indicate which of the following options best describes you: (please tick all that apply) Patient Carer Parent/guardian Member of the public Voluntary and community sector staff/trustee Other (please specify below) Please tick the things that you are most interested in; (tick all that apply). Please note: this list is not exhaustive, but includes examples of activities Being a member of a study team or steering group Being a research participant Setting research priorities/deciding how funding is spent Being part of a discussion/focus group Carrying out and/or analysing research data alongside researchers Completing questionnaires/surveys Designing and writing lay summaries or other 'patient friendly' documents Developing, designing, planning research ideas and funding bids Identifying future research priorities Generating research questions Planning community events and awareness raising activities Reading and commenting on research papers Representing the community perspective Speaking at public events Undertaking interviews with research participants Using social media to promote research activities Other (please specify below) Do you have a particular interest in any of the following topics/health areas? (Tick all that apply) BME health Cancer Children’s health Dementia Diabetes Digital Technologies to manage conditions Heart and circulatory conditions e.g. high blood pressure Infectious diseases Kidney disease Maternity services Mental health and wellbeing Men’s health Musculoskeletal Neurology (brain, spinal cord and nerves) Older people Respiratory (breathing and lungs) Sexual health Skin conditions Stroke Vaccines Women’s health Other (please specify below) Protected characteristics monitoring; Age: <18 18 to 24 25 to 49 50 to 69 70+ Other (how would you describe yourself, fill in the box below) Male Female Prefer not to say Other (how would you describe yourself, fill in the box below) Disability status Yes No Prefer not to say What do we mean by a “disability"? The Equality Act of 2010 defines disability as: “a physical or mental impairment with long term, substantial adverse effects on ability to perform day to day activities.”Ethnicity: White English/Welsh/Scottish/Northern Irish/British Irish Gypsy or Irish Traveller European Any other White background (please state below) Asian/Asian British Indian Pakistani Bangladeshi Chinese Any other Asian background (please state below) Black/Black British African Caribbean Any other African/Caribbean/Black background (please state below) Mixed Asian and White Black African and White Black Caribbean and White Other Mixed background (please state below) Other Arab Prefer not to say Any other background (please state below) Religion and belief Baha’i Buddhist Christian Hindu Jain Jewish Muslim No Religion Sikh Prefer not to say Other (please state below) Sexual orientation Bisexual Gay women/lesbian Gay man/homosexual Heterosexual/straight Prefer not to say Marital Status Civil partnership Married Single Separated/divorced Prefer not to say Supporting StatementUsing the space, please tell us a little bit about your interests and your reason for wanting to become a member of the Community Partners Panel?Where did you hear about this opportunity, please specify below: Please read our Privacy Policy which contains further information about how we use your personal data including your right to withdraw your consent at any time and your various rights under data protection legislation, for example, rights of access to your data. I agree to the privacy policyPlease read our Privacy Policy which contains further information about how we use your personal data including your right to withdraw your consent at any time and your various rights under data protection legislation, for example, rights of access to your data. Share this page
