IDEOM Stakeholder Application

IDEOM Stakeholder Application
International Dermatology Outcome Measures (IDEOM) is a non-profit organization seeking to develop and validate measures throughout dermatology. IDEOM strives for the establishment of patient-centric outcomes to enhance the research and treatment of dermatological conditions. IDEOM seeks to bring together physicians, researchers, government agencies, pharmaceutical companies, payers and patients from around the globe to develop and validate measures throughout the field of dermatology.

To become a stakeholder with IDEOM, participation in Delphi surveys, web conferences, workgroups, and in-person meetings will be required. IDEOM provides a travel reimbursement for all stakeholders, with the exception of our industry and payer stakeholders.

Please complete this application and submit a letter of interest in developing outcomes in dermatologic conditions or your personal experience. Please also submit a CV (patients need not submit a CV).

IDEOM POLICY:
To remain eligible for travel reimbursement for all in-person meetings, all stakeholders MUST attend the two (2) days of the annual meeting in its entirety.

Please contact Amanda Pacia, IDEOM Association Manager, at amanda@dermoutcomes.org with any questions.
Name

First NameLast Name
Degree
Email
example@example.com
Academic Title
Institution/Company
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.
Type of Stakeholder category you would like to participate in:

PhysicianIndustryPatient Research PartnerGovernmentPatient AdministrationNon-profitPayerCaregiverResearcherOther
Type of Stakeholder you would like to participate as:*

PhysicianIndustryPatient Research PartnerGovernmentPatient AdministrationNon-profitPayerCaregiverResearcherNurseMedical StudentFellow/Resident
Which workgroup(s) are you interest in participating in?

PsoriasisPsoriatic ArthritisHidradenitis SuppurativaAcneActinic KeratosisVitiligoCutaneous T-Cell LymphomaConnective Tissue DiseasesAlopecia AreataItch
PRIMARY workgroup you are interested in participating in:*

AcneActinic KeratosisConnective Tissue DiseasesCutaneous T-Cell LymphomaHidradenitis SuppurativaItchPsoriasisPsoriatic ArthritisVitiligo
Other workgroup(s) you are interested in participating in:

AcneActinic KeratosisCutaneous T-Cell LymphomaHidradenitis SuppurativaItchPsoriasisPsoriatic ArthritisVitiligo
Who recommended you / how did you hear about IDEOM?*
List any significant publications in dermatology (if applicable):
Upload CV (not required for patients, but you are welcome to upload if you have)

Cancelof
Brief narrative bio for any introductions:
Please explain your interest in IDEOM:*
Should be Empty: