| Name of the PPI activity |
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| Contact name |
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| Contact phone (Required) |
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| Contact email (Required) |
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| What is the PPI activity aiming to achieve? (100 words max) |
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| What PPI activity are you planning to do? (100 words max) |
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| How will you involve under-represented groups in your PPI activity? |
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| Who is your target audience? |
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| * If 'other' please describe |
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| Dates of PPI Activity |
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| Are these dates: (if unsure, leave blank) |
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| Where will PPI activity take place? |
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| * If 'other' please describe |
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| How will you inform participants of the outcome? |
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