Consumer Group Eligibility and Registration

Blood Cancer Consumer Engagement Program Eligibility and Registration
Welcome to the Consumer Engagement Program eligibility and registration. The following questions will help us understand a little bit more about you and determine if you're eligible to join the group.
Consent and contact details

Let's start with a few contact details and information about your background, so we can get in touch with you if you're eligible to join the Consumer Engagement Program.
Do you consent for Leukaemia Foundation to maintain a record of your personal contact and health details within our privacy-protected database?*

YesNo
Your contact details
Your name*

First NameLast Name
Email*
example@example.com
Your postcode*
Postcode
Phone number*
Your date of birth*

DayMonthYear
Next we'd like to know a little more about you.
Your gender*
Are you of Aboriginal or Torres Strait Islander origin?*
What is your ethnicity?*
I am ...*
When did your loved one become deceased?*
What is your relationship to the person living with blood cancer?*
What was your relationship to the person with blood cancer?*
What is the age of the person living with blood cancer?*
Blood cancer diagnosis (answer for your loved one if you're not the patient)*

AmyloidosisLeukaemiaLymphomaBlood DisorderChronic Myelomonocytic Leukaemia (MDS/MPN)Myelodysplastic syndrome (MDS)MyelomaMyeloproliferative neoplasms (MPN)Other
Do you know your amyloidosis subtype?*
Do you know your blood disorder subtype?*
Do you know your leukaemia subtype?*
Do you know your lymphoma subtype?*
Do you know your MDS subtype?*
Do you know your myeloma subtype?*
Do you know your MPN subtype?*
What was their blood cancer diagnosis?*

AmyloidosisLeukaemiaLymphomaBlood DisorderChronic Myelomonocytic Leukaemia (MDS/MPN)Myelodysplastic syndrome (MDS)MyelomaMyeloproliferative neplasms (MPN)Other
What is the name of your diagnosis? (if known)*
When were you first diagnosed (answer for your loved one if you're not the patient)?*

DayMonthYear
At what stage are you at with your disease (for your loved one if you're not the patient)?*
If currently being treated, did you start your current treatment more than 6 months ago?*
When did you finish your initial treatment (answer for your loved one if you're not the patient)?*
If you have relapsed and been re-treated, when did this commence (answer for your loved one if you're not the patient)?*
Did you receive a stem cell transplant (SCT) or cellular therapy (e.g. CAR-T)?*

YesNo
What type of SCT/cellular therapy did you receive?*

Autologous stem cell transplantAllogeneic (donor) stem cell transplantCAR-T therapyOther
What type of allogeneic (donor) stem cell transplant?*
Congratulations!

You're now eligible for the Blood Cancer Consumer Engagement Program and almost at the finish line!

The final set of questions has to do with getting to know you better and customising our requests for future projects, so please keep going.
Please select your areas of interest in relation to engagement opportunities (tick all that apply)*

Ambassadors / Advocates (i.e. community influencers) *‘Blood Buddies’ (1:1 peer support) *Campaign stories (e.g. featuring in fundraising appeal or newsletters)Clinical trials design committees / participationCommittee participation *Fundraising spokespersons *Government advocacy (e.g. Pharmaceutical Benefits Advisory Committee submissions) *Leukaemia Foundation Consumer Advisory Board *Leukaemia Foundation policy feedbackLeukaemia Foundation service improvement feedbackMedia requests *Participating in blood cancer webinars or support groups as co-facilitators *Participating in the creation of new programs / services and pilot-testingPodcasts *Research participation (e.g. interviewed by researchers around the blood cancer journey)SurveysTV commercials of Leukaemia Foundation activities *Other
In your words, how would you summarise your blood cancer patient experience?*

0/200
How much time do you think you could spare for future engagement opportunities?*
How confident are you speaking in front of an audience?*
How comfortable are you with the use of technology?*
How would you prefer to be recorded?*
How would you like your story or voice to be shared?*
Do you have any special skills, talents or qualifications we should know about?*
Have you previously received support services from the Leukaemia Foundation?*

YesNo
Please select which support you received? (tick all that apply)*

Accommodation (internal / external)Education servicesFinancial assistanceInteractions & support with Blood Cancer Support CoordinatorsTransportOther
What's top your motivation for being part of this Consumer Engagement Program?*

Advocate for the blood cancer communityCo-host support groups and educational eventsConnect with others in the survivorship phaseContribute to governance and policy-makingDevelop new services and programsElevate Leukaemia Foundation causes in the communityJoin a consumer advisory panelParticipate in blood cancer researchShare my lived experience with blood cancerVolunteer my time or talentsOther
Thank you so much for your time. Please ensure you click on SUBMIT to finalise your registration.

You'll soon receive a welcome letter from our Consumer Engagement Coordinator, Matt Eby. Remember to check your spam/junk mail folder if you haven't received anything in the coming days for an email from consumers@leukaemia.org.au
Thank you, but unfortunately you're not eligible to join the Consumer Engagement Program at this time based on your answers. We'd really appreciate it if you could click on SUBMIT to complete the form, even though you're not eligible.

You're welcome to try to re-qualify in the future, just visit the Consumer Engagement Program webpage and register.

In the meantime, if you need to talk to our Leukaemia Foundation Living Well team or require support services please call 1800 620 420 or complete our online request for services.
Thank you, but unfortunately you're not eligible to join the Consumer Engagement Program at this time based on your answers.

You're welcome to try to re-qualify in the future, just visit the Consumer Engagement Program webpage and register.

In the meantime, if you need to talk to our Leukaemia Foundation Living Well team or require support services please call 1800 620 420 or complete our online request for services.
I acknowledge that consent was obtained from the patient or parent/caregiver to complete this referral on their behalf*

Yes, I agree
By clicking 'I agree' and submitting this form below, you acknowledge that consent was obtained from the patient or parent/caregiver to complete this referral on their behalf. Additionally, both you and the patient or parent/caregiver consent to your details being used by the Leukaemia Foundation to make contact about relevant blood cancer services and information.You also consent to the Leukaemia Foundation’s Terms of Use, Privacy Commitment and Privacy Notification Statement.
Please verify that you are human*
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Blood Cancer Consumer Engagement Program Eligibility and Registration

Consent and contact details

Your contact details

Next we'd like to know a little more about you.

Congratulations!