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Consumer Research Training 2015 Expression of Interest Form Research consumers play an important role in the research process by ensuring that research is conducted with the community it is intended to benefit. Cancer Council NSW’s Consumer Research Training is suitable for people with an interest in cancer research and a willingness to work directly with cancer researchers to provide the consumer perspective to their research projects. The training equips consumers to assist researchers who seek consumer involvement in their research projects. It is expected that after completing the training, consumers will make themselves available as a consumer representative to appropriate research projects. Cancer survivors and their carers, family and friends are welcome to participate in this training. If you are from outside Sydney and able to stay with family or friends during the training, we will ask you to do so; but aside from this, there will be no costs incurred by participants. Personal and contact details Name Postal address Phone Mobile Email Date of birth Are you of Aboriginal or Torres Strait Islander origin? (optional) Do you identify as a member of a cultural or ethnic group? If so, which group? (optional) 1 Cancer experience Please tell us about your personal experience with cancer. Example: My mother was diagnosed with lung cancer in 2011, and received chemotherapy and radiotherapy. Your experience Type of cancer, when diagnosed, treatment undertaken Diagnosed with cancer yourself Carer of cancer patient Family member diagnosed Friend diagnosed No experience with cancer Other (please describe) Training and consumer experience Have you previously been or are you currently part of a cancer consumer organisation? YES NO If yes, please describe: Have you previously been trained as a consumer representative or consumer advocate? YES NO If yes, please describe who provided the training, what it equipped you to do, and when it was held: Are you planning to attend this training on behalf of a research organisation or cancer charity? YES NO If yes, please include the name of this organisation/charity and your contact person there: 2 Criteria Please outline how your skills and experiences meet each of the criteria in the blank spaces below (please provide a maximum of 200 words per criterion). Experience Essential: Experience with cancer and/or experience representing the interests of consumers. Desirable: Good links with consumer networks, associations, societies, or groups. Desirable: Up to date with current consumer issues. Special skills Essential: Willing to learn about medical and research language. Specialist knowledge Essential: Ability to ‘think like a consumer’ and consider the questions that patients may ask. Desirable: Previous experience working as a consumer representative. Personal qualities Essential: Good communicator (both written and verbal). Desirable: Ability to give feedback to the researcher to help develop their research program. 3 Your interest in this role What is it that interests you about working directly with researchers as a consumer representative? Other life experiences Please provide any other information you believe is relevant to making you a good fit for the role of consumer representative on research projects Other questions Would you like to receive research newsletters from Cancer Council NSW? (We will not send you requests for donations) YES NO How did you hear about this training? 4 Availability Are you available to participate in the training workshop on the 20th November 2015 or add to a list for 2016 training? YES / NO Are you willing to work directly with cancer researchers by acting as a consumer representative on their research projects? YES / NO YES / NO Your details will be given to Cancer Voices NSW who provide a ‘matching’ service which links researchers and consumer representatives. If you do not wish to be listed on the Cancer Voices NSW database, you may opt out of this expectation at the training. Please see Privacy Statement on page 6 of this document. The training will be held in Woolloomooloo, Sydney, NSW. If you are coming from outside of Sydney, will you be able to stay with friends or family? There are no costs to participants, so if you need accommodation and flights, we will cover the costs. However, as we have a limited budget, if you are able to stay with friends or family it will mean that we can afford to have a larger number of people attend the training. Please return completed Expression of Interest forms to: John Williams Research Governance Officer PO Box 572, KINGS CROSS NSW 1340 153 Dowling Street, Woolloomooloo NSW 2011 Tel: (02) 9334 1993 Email: [email protected] We look forward to hearing from you - thank you very much for your time and interest. 5 Privacy Statement The Cancer Council NSW is collecting the information in this form for the purpose of registering you for this event, program or campaign. If you do not provide this information, you may not be able to participate. Cancer Council may use your details to send you information about Cancer Council’s and third parties’ products, services, events, fundraising or any other activities which we consider may be of interest to you. You may unsubscribe by contacting us. We may disclose your information to our contractors, third party service providers, volunteers and agents that may assist Cancer Council. We may also disclose your information to like-minded organisations to contact you with information that may be of interest to you, such as Cancer Voices NSW, to enable them to contact you about opportunities for you to act as a consumer representative on cancer research projects. Cancer Council will handle your personal information in accordance with the Privacy Act 1988 (Cth) and its Privacy Policy (which is available on our website or which can be provided to you on request). The Privacy Policy also explains how you can contact us to access and correct your personal information, or make a complaint about a breach of the Australian Privacy Principles. For more information, please contact us via telephone on (02) 9334 1993 or via email at [email protected]. 6