MBCA | INDUSTRY MEMBER REQUEST FOR PATIENT COLLABORATION
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The Patient Advocate Advisory Group (PAAG) of the MBC Alliance includes individuals who are living with metastatic breast cancer and who are willing to collaborate with industry members on initiatives that would benefit from the patient perspective. If your organization would like to engage group members, please complete the following request form.
 
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Tell us about you and your organization.

First Name:
Last Name:
Company Name:
Email Address:
emailaddress@xyz.com
Preferred Phone:

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Describe the initiative or project for which you are seeking patient input

 

1000 characters left.
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What specific skills or experience do you wish the patient advocate to have?

 

350 characters left.
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Is the request limited to a specific demographic or disease sub-type? If so, please comment.
YES
NO
  • Comment:

  • 500 characters left.
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 How many patient advocates are you requesting for this work?

 

50 characters left.
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How many hours will the patient advocate(s) be expected to devote to this project?

 

50 characters left.
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For what length of time (months, days, etc.) will the patient advocate be expected to participate?

 

50 characters left.
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How will the project work be conducted?

Via ZOOM
Via Telephone
In-Person
At a Conference or Other Event
Other  
  • Comment:

  • 500 characters left.
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Will the work require the patient advocate to travel? If so, please comment.
YES
NO
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  • 500 characters left.

If travel is required, how will the patient advocate's transportation, lodging, and food costs be handled?

We will handle everything in advance.
We will reimburse - once receipts have been submitted.
Expenses will be the responsibility of the patient advocate.
Other  
  • Comment:

  • 500 characters left.
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Will the patient advocate be offered an honorarium for their participation?

YES
NO
Other  
  • Comment:

  • 500 characters left.

Please feel free to add any additional pertinent information.

 

1000 characters left.
If you have additional questions or concerns, please contact Laurie Campbell, Executive Director if the Alliance at laurie@mbcalliance.org.