Cancer Prevention and Research Institute of Texas

ADVOCATE REVIEWER APPLICATION FORM

For information regarding the applicationprocess and eligibility, please visit

Name:

Mailing Address:

City: State: Zip Code:

Primary Phone Number:

Secondary Phone Number:

E-mail Address:

Occupation:

Highest Degree Attained:

High School/EquivalentPh.D./equivalent

A.A.J.D.

B.A./B.S.M.D./DDS

M.A./M.S.Other:

MSW/MPH

Are you a (choose all that apply):

Survivor/patient

Family member/caregiver

Member of an advocacy organization

Have you served on one or more of the following peer review panels within the past 3 years? Indicate dates of service.

CPRIT

Dates of service:

National Institutes of Health (NIH)

Dates of service:

Department of Defense (DoD) Congressionally Directed Medical Research Programs

(CDMRP)

Dates of service:

Federal Drug Administration (FDA)

Dates of service:

Patient-Centered Outcomes Research Institute (PCORI)

Dates of service:

If you have not served on one or more of the panels listed above within the past 3 years, have you attended one or more of the following advocate training programs within the past3 years? Indicate dates of attendance.

American Association for Cancer Research (AACR) Survivor<->Scientist Program

Dates of attendance:

American Society of Clinical Oncology (ASCO) Research Review Sessions for

Patient Advocates

Dates of attendance:

Research Advocacy Network (RAN) Advocate Institute

Dates of attendance:

National Breast Cancer Coalition (NBCC) Project LEAD

Dates of attendance:

SUBMISSION REQUIREMENTS

All applicants must attacha current resumé (volunteer, community, and/or employment experience) or curriculum vitae.Applicants who have attended training but have not yet served on a peer review panel must also submit a letter of recommendation from a community-based organization and submit a personal statement on advocacy and education.

The personal statement should include:

How you will represent others living with cancer

How you keep informed about issues or developments related to cancer and describe what resources you routinely use (e.g., support groups, internet, library, journals, seminars, or classes)

Description of a situation in which different views represented a barrier to the completion of a task and your approach to overcoming this

How you would evaluate a scientific proposal in which the project proposed challenged your ideas, values and/or beliefs

Submit the final applicationpackage to:

Cancer Prevention and Research Institute of Texas

Email:

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