Pharmacists Optimizing Cancer Care
Patient Advisory Panel Applicant Form
How did you hear about the Hematology/Oncology Pharmacy Association (HOPA) Patient Advisory Panel?
The overall vision of the Patient Advisory Panel is that panelists will use their experiences and expertise to provide feedback and guidance on the programs and initiatives of the Hematology/Oncology Pharmacy Association. How might your experiences contribute to this vision?
Do you have prior involvement with patient volunteer efforts? If so, please specify previous roles and organizations.
Please select all of the treatment options you have experience with.
Intravenous (IV) Chemotherapy
Immunotherapy (including Stem Cell Transplant and CAR T-cell Therapy)
Please enter the other treatment option you have experience with.
Please provide some background regarding your disease experience. Examples may include stage, tumor type, treatment approaches used, and clinical trial participation.
Are you open to communicating and describing your experiences publicly?
Are you open to communicating and describing your experiences through a survey?
Would you be willing to travel if an opportunity to advocate with and on behalf of an oncology pharmacist arose?*
*Due to the COVID-19 pandemic, any travel related to the Patient Advisory Panel will not occur until deemed safe. HOPA will continue to follow the Centers for Disease Control and Prevention's (CDC) travel guidelines. Panelists may be asked to participate in virtual events in lieu of attending in-person events.
Have you ever been asked to provide input on a research project, training for health care providers, or educational materials for patients? If so, please describe.
HOPA is committed to diversity, equity, and inclusion in all of our initiatives, including the Patient Advisory Panel. Please include any information that is unique about your journey. Examples include race/ethnicity, gender/sexual orientation, age, and place of residence (rural vs. urban vs. suburban).
I have read and agree to the terms and conditions outlined in the
Patient Advisory Panel Guidance Document