Name
First Name
Last Name
Email
example@example.com
County
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which of the following best describes your experience of cancer?
I am living with cancer
I have had cancer
I am/was a carer of someone with cancer
My family member has/had cancer
Other (please describe)
Please describe:
What year was it diagnosed?
Have you ever taken part in a clinical trial?
Yes
No
What type of cancer was the trial for?
(e.g. breast, lung, prostate)
Did your trial involve taking a medicine, or participating in a new treatment?
Yes
No
Not Sure
Are you involved in any cancer groups or patient groups? (e.g. Irish Cancer Society, Melanoma Support Ireland, Plurabelles)
Yes
No
Which ones?
While previous experience is not necessary, have you ever been involved in ‘public & patient involvement’ (PPI) work before?
Yes
No
What were you involved in?
Can you tell us what motivates you to get involved with the Patient Consultants Committee of Cancer Trials Ireland?
Is there anything else you would like to tell us about your own circumstances or how you can take part in PPI activities, as listed on this page and described in the videos?
Submit
Should be Empty: