Pathway Boards and Expert Reference Groups

Patient and carer representatives - Expression of Interest Form

If you have any queries, would like to find out more about what this role will involve, or whether it would be suitable for your interests and experience, please don’t hesitate to contact us on 07950 960 159 or 020 3447 2779 or email .

If you are ready to apply, please complete this form and return it to: by midnight Sunday 29 April 2018.

Your contact details
  1. Name

  1. Postal address

  1. Email address

  1. Phone number

  1. Which Pathway Board or Expert Reference Group are you interested in joining?
For a list of current vacancies, please see [insert link to document here].
Your experience of care and treatment
  1. Are you a patient or a carer / family member?
Please note that by ‘carer’ we mean caring in a personal, unpaid capacity, rather than as a professional.
  1. What type(s) of cancer have you, or the person you care for, been diagnosed with?

  1. Are you, or the person you care for, currently receiving treatment? If not, when did you last receive treatment?
In order to be eligible for this role, you, or the person you care for, must have received treatment within the last 5 years.
  1. Which hospitals did you, or the person you care for, go to:
  1. initially
  2. for treatment
  3. for follow-up appointments
Appendix 1 includes a map of the 17 hospitals covered by the UCLH Cancer Collaborative.
Your interests, skills and experiences
  1. Are you currently involved with any groups or organisations:
For example –
  • Patient panels
  • Advisory groups
  • Patient forums
  • Patient involvement network
  • Health champions network
  • Peer support group
  • Tumour specific support group
  • Faith groups
  • Community groups not related to cancer

  1. We are looking for people who can broadly represent the diverse views and experiences of people affected by cancer and help drive improvements to patient experience.
What appeals to you about participating in this Pathway Board or Expert Reference Group?
(max. 200 words)
  1. Why do you think it is important for people affected by cancer to get involved in helping shape NHS services?
Tell us what your approach would be to working collaboratively to improve services.
(max. 200 words)
  1. How do you think you could contribute to this Pathway Board or Expert Reference Group?
How will you ensure you bring a wide perspective?
Please describe your relevant skills and experience, with reference to the role description.
(max. 400 words)
Additional information
The information you provide in response to the following questions will help us to support you effectively. It will not be used to assess your suitability for the role.
  1. Do you have any access or other support needs to help you to participate fully?
We will make reasonable adjustments to support you wherever possible.
  1. a. Are you currently working?
  1. What is your occupation?
We welcome people from all backgrounds and walks of life to our network. You do not have to answer this question, but it will help us to understand your skills and interests.
  1. Would you like to receive regular email updates about future involvement opportunities and news about the work of the Collaborative?
/ Please delete as applicable:
Future involvement opportunities:
Yes / No
E-Bulletin News:
Yes / No
  1. If you answered ‘yes’ to question 15, please select from the following list,activities of interest to you:
/ Types of involvement and engagement opportunities:
  • Joining a steering group
  • Joining a project board
  • Attending a focus group or workshop
  • Attending a community engagement event
  • Giving remote feedback on documentsby email – e.g. patient information leaflets, publicity materials
  • Sitting on a selection panel
  • Going on a site visit
  • Developing a patient survey
Interests related to cancer:
  • Public awareness of cancer
  • Early diagnosis
  • Improving patient pathways
  • Provision of accessible information for patients
  • Living with and beyond cancer
  • Education and training for health professionals

Thank you for your interest in this role. We will respond to all applicants to let you know the outcome within 4 weeks of the deadline.