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Wessex Cancer Alliance PIN Expression of Interest Form
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If you would like to volunteer for the
Wessex Cancer Alliance
’s Patient, Carer and Public Involvement Network, please complete and return the expression of interest form below. The network is being managed by
Wessex Voices
, who support the Alliance with their patient and public involvement.
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1.
Question 1.
Name
Required
- Required.
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2.
Question 2.
Contact details
Required
- Required.
This question requires an answer
Mobile phone
Telephone (landline) number
Mailing address
Postcode
Email address
*
3.
Question 3.
Preferred method of contact
Required
- Required.
Mobile phone
Telephone (landline) number
Post
Email
*
4.
Question 4.
Please tell us if you are (select all that apply)
Required
- Required.
A patient
A former patient
A carer (family/unpaid)
A family member or supporter of someone with cancer
Member of the public
Cancer support group lead
An organisation, including cancer charities, VCSE, faith sector, statutory sector
Other (please specify):
This is required
Input box for - Other (please specify):
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5.
Question 5.
Do you have an interest in a specific cancer? Please select all that apply.
Required
- Required.
All cancers
Breast
Bowel
Lung
Head and neck
Skin
Pancreas
Other (please specify):
This is required
Input box for - Other (please specify):
*
6.
Question 6.
Is there a particular area of the Wessex Cancer Alliance’s work that you are interested in?
Required
- Required.
Prevention
Earlier diagnosis
Faster diagnosis
Treatment and care
Children and young people’s cancer services
Living with cancer
All of the above
I don’t know
Other (please specify):
This is required
Input box for - Other (please specify):
7.
Question 7.
Please specify what level of involvement you would like to have?
(A) would like to just receive the Wessex Cancer Alliance patient, carer and public information around involvement activities
(B) would like to be an active volunteer with the Alliance on various projects, events and feedback initiatives.
Please note you can change your level of involvement at anytime.
Information and updates only
Active Volunteer
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8.
Question 8.
If you would like to become a active volunteer, please select all the ways you might like to get involved (sharing your preferences does not automatically commit you to doing these things)
Required
- Required.
Wessex Cancer Alliance’s Patient and Public Involvement Steering Group
Cancer pathway reviews
Projects
Attending meetings
Giving feedback on information
Sharing your experiences at events
Giving feedback via surveys, emails or on the phone
Other (please specify):
This is required
Input box for - Other (please specify):
9.
Question 9.
Are there any ways we can support you? (E.g. providing you with translations or accessible information, paying childcare expenses, providing training to access online meetings, etc.)
No
Yes (please specify):
This is required
Input box for - Yes (please specify):
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