NICE Workshop Request Form

1. Name *

2. E-mail address *

3. Job title / Role *

4. NICE guidance reference and title *

5. Which directorates will be required to contribute? *

	Yes	No
Adult	Adult Yes	Adult No
Children and Family Health Devon	Children and Family Health Devon Yes	Children and Family Health Devon No
Corporate services	Corporate services Yes	Corporate services No
Cross-directorate Initiatives	Cross-directorate Initiatives Yes	Cross-directorate Initiatives No
IPP	IPP Yes	IPP No
Older people	Older people Yes	Older people No
Professions	Professions Yes	Professions No
Secure	Secure Yes	Secure No
Specialist services	Specialist services Yes	Specialist services No

6. In order for this workshop to go ahead, you need to identify key individuals who are required to attend
These are essential people who will represent, help inform and contribute to the Baseline Assessment Tool (BAT). For
example, Directorate Clinical Leads, Practice Leads, Service Leads etc.
Please provide their full names (first name and surname) *

7. Please suggest the dates and times which are most suitable to hold the workshop (maximum of 3)

Please allow approximately 3 hours per workshop *

8. Partnership Agreement

Please read this agreement and click 'Yes' below to confirm your agreement to this partnership contract:
*

Yes
No

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