researchpassportapplicationform.docVIP

Research Passport Application Form Please refer to the guidance notes before completing the form. Section 1 - Details of Researcher To be completed by Researcher 1. Surname: Prof Dr Mr Mrs Miss Ms Other Forename(s): Home Address: Work Tel: Mobile: Email: 2. Date of birth: Gender: Male Female Ethnicity: National Insurance number: 3. Professional registration details, if applicable (Doctors undertaking any form of medical practice should confirm they have a licence to practise). N/A 4. Employer: or place of study: Work Address/Place of Study: Post or status held: Section 2 - Details of Research To be completed by Researcher 5. What type of Research Passport do you need? Project-specific Multi-project If you will be conducting one project only please complete the details below. If you anticipate that you will be undertaking more than one project at any one time, please give details in the Appendix. Project Title: Project Start Date: End Date: Proposed start and end-date of 3-year Research Passport: Start Date: End Date: NHS organisation(s): Dept(s): Proposed research activities: Manager in NHS organisation: Section 3 – Declaration by Researcher To be completed by Researcher 6. Have you ever been refused an honorary research contract? Yes No Have you ever had an honorary research contract revoked? Yes No If yes to either question, please give details: I consent to the information provided as part of this Research Passport and attached documents being used, recorded and stored by authorised staff of the NHS organisations where I will be conducting research. Signed: Date: When Sections 1-3 have been completed, the researcher should forward the form to the appropriate person to complete Se