Updated Consumer Membership Form (1)

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Membership is free and open to all members of the public with an interest in primary care cancer research. We are particularly interested in hearing from people who have lived experience of cancer, including carers.

By filling in this form you are becoming a PC4 Community Network member and will receive our quarterly consumer newsletter. We do not provide your details to anyone else without your permission, and you can opt-out at any time.

We ask about your details and interests so we can identify specific research projects that are particularly relevant to your lived experience and areas of interest.

Your Details

Title*

First Name*

Last Name*

Suburb/Town*

Postal Code*

State*

Region*

Please choose which location you spend most of your time in.

Country*

Email*

Mobile*

Demographic Information

We welcome interest from people from all backgrounds and locations.

Gender Identity*

Current Age*

Please specify:*

Lifestyle*

Student

Working

Retired

Volunteer

Other

Please tick the option/s that applies to your current circumstances.

Please specify:*

Briefly outline your occupation or interests, including previous roles if now retired or not currently employed.*

Priority Population Groups

There are significant health inequities among specific population groups within Australia that lead to poorer cancer outcomes for these communities. PC4 is dedicated to including priority population groups as part of our research to help achieve health equity for all Australians. We may reach out to you if there are opportunities for involvement that align with your experiences. All questions are optional. You may skip a question by selecting “Prefer not to say”.

To learn more about the priority population groups, please visit the Australian Cancer Plan here.

Do you speak a language other than English at home?*

Yes

Prefer not to say

What language(s)?

Do you identify as an Aboriginal and/or Torres Strait Islander?*

Yes – Aboriginal

Yes – Torres Strait Islander

Yes – Both Aboriginal and Torres Strait Islander

Prefer not to say

Are you part of the LGBTIQA+ community (including caring for someone who is part of the LGBTIQA+ community who has had a cancer diagnosis)?*

Yes

Prefer not to say

Do you live or have lived experience with disability (including caring for someone with a disability who has had a cancer diagnosis)?*

Yes

Prefer not to say

Do you live or have lived experience with mental illness (including caring for someone with mental illness who has had a cancer diagnosis)?*

Yes

Prefer not to say

Cancer Lived Experience

Which of the following best describes your cancer experience/s (if any)?*

Diagnosed with cancer myself

Carer

Family member diagnosed

Friend diagnosed

No experience with cancer

Other

Please specify:

How old were you or someone you cared for when they were diagnosed with cancer?*

If not applicable or prefer not to say, enter “not applicable” or “prefer not to say”

Your Research Interests

What are your area(s) of research interest? Tick as many as you like.

Cancer Site*

Bone

Breast

Genitourinary

Gynaecological

Haematological

Head and Neck

Hepatobiliary

Lower GI

Lung

Metastatic

Paediatric/Adolescents and young adults

Rare

Skin and Melanoma

Upper GI

Other

Please specify:*

Research Area*

Prevention, screening and early diagnosis

Treatment and shared care

Survivorship and symptom management

End-of-life care

Carer support

Other

Please specify:*

Please provide details on your cancer experience/s including cancer types/s*

Consumer Experience

Have you had previous experience as a cancer consumer?**

Yes

Have you received any previous training to be a consumer representative?*

Yes

Have you had experience in clinical trials as a consumer?*

Yes

Are you currently a member of any other cancer research groups or consumer organisations?*

Yes

Memberships*

AGITG

ASSG

ALLG

ANZBCTG

ANZCHOG

ANZGOG

ANZMTG

ANZUP

BCT

CNSA

COGNO

COSA

CST

PoCoG

RACGP

TROG

Other

Please specify:*

Please provide details (name of group/s, your role and recent activities)*

Please describe any committee or working group experience you have not described above (it doesn't have to be related to cancer)*

Life Skills – Personal and Professional

Community members may be contacted about opportunities to contribute their lived experience to research activities such as: joining PC4’s Community Advisory Group (CAG), reviewing a new research idea (online), reviewing a new research idea at a workshop, reviewing a research project grant application, reviewing plain language summaries of project results for the public and/or joining a project as part of the project team or steering committee.

People develop many skills from work, social, personal and family experiences. Please think broadly when you answer these questions.

Please describe how your life skills may contribute to our research activities (including experience on committees/working groups) not described previously*

Effective communication is key to being an effective representative. Please outline your communication strengths*

Where did you hear about PC4?*

Please specify:*

Thank you for your interest in PC4!

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