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NHS
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Primary Care Trust
NHS
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Participant Agreement to attend Self-Management Course and contribute to research

(see list)

All this information will be treated as confidential.

Personal information is covered by the Data Protection Act.  Research may be carried out to monitor its effectiveness, do you agree that you are happy to participate in the research and fill in a questionnaire?  All information you provide will be treated as confidential.  If you agree we will contact you for this purpose.

Press ‘Submit’ to send your form.  If you do not receive confirmation of your submission within a few days please contact one of the names on the main page.

 

Only press ‘Reset’ if you wish to clear all the entries without sending the form.

Course Venue
First / Nick name
Surname
Address line 1
Address line 2
Address line 3
Post code
Daytime telephone
Evening telephone
Are you travelling by car?
Do you need transport?
What health conditions
 do you have?
Do you use a wheelchair?
Do you have any special
 requirements?
Do you have any other
 issue we need to know
 about?
A contact name/number
 (to be used only in an
 emergency during the
 course)
Where did you hear
 about EPP?
The venues and dates for 2008
 will be listed here shortly.
 Please keep checking from mid-January