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Direct Delivery Team Support Request Form v0.1
Please contact your CRN East Midlands DDT Lead to discuss your request before you complete this form.
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* Indicates required question
Your email address
*
Your answer
Your full name
*
Your answer
Organisation/Trust/Site
*
For eg. University Hospitals of Leicester NHS Trust
Your answer
What county is support required in?
*
Derbyshire
Leicestershire
Northamptonshire
Nottinghamshire
Lincolnshire
Required
Location
*
Prison
Hospital
GP Surgery
Community & Mental Health Trust
Care Home
Local Authority
Hospice
Domicillary Care
Charity
School
Dentist
University
Community Centre
Study name(s)
Your answer
Study specialty
Ageing
Anaesthesia, Perioperative Medicine and Pain Management
Cancer
Cardiovascular Disease
Children
Critical Care
Dementias and Neurodegeneration
Dermatology
Diabetes
Ear, Nose and Throat
Gastroenterology
Genetics
Haematology
Health Services Research
Hepatology
Infection
Injuries and Emergencies
Mental Health
Metabolic and Endocrine Disorders
Musculoskeletal Disorders
Neurological Disorders
Ophthalmology
Oral and Dental Health
Primary Care
Public Health
Renal Disorders
Reproductive Health and Childbirth
Respiratory Disorders
Stroke
Surgery
Urgent Public Health
Other:
Reason for request
*
Vacancy cover until recruitment to post
Long term sick leave cover
Maternity leave cover
Sabbatical/Secondment cover
Recruitment to Urgent Public Health/High Priority study
Data lock timeframe
Target timeframe
Pump priming
Research naive
Smaller organisation
Staff training time
Study extension
Holiday cover
Reduced staffing/lacking capacity
Shadowing/Mentorship support
Multiple site cover
Follow up support
Required
Duties required
Recruitment / Consenting
Clinical support - E.g. Clinical observations, study visits, venepuncture, laboratory, medicines management
Non clinical support - E.g. Administrative, data entry, questionnaire/survey distribution, archiving
Training / Mentoring
Whole Time Equivalent required
1 day = 0.2 WTE
Your answer
How long will you require support for?
Please enter number of months
Your answer
When do you want support to start from?
MM
/
DD
/
YYYY
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