Participant Advisory Panel Interest Form

Do you have ideas on how we can spread the word about All of Us? Or how to make it easier for people to join? If so, we want to hear from you!

We are looking for central Massachusetts All of Us participants to join a new Participant Advisory Panel and give us feedback and advice on the program. We want to hear your suggestions and concerns so that we can make the program the best that it can be.

Please complete the survey below.

Thank you!

Date of Survey

M-D-Y

First Name

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Last Name

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Mailing Address: Number and Street

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Mailing Address: City or Town

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Mailing Address: State

(choose one)

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Mailing Address: Zip Code

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Preferred Phone

Please tell us a little about why you are interested in being an Advisor.

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Please list any research topics that are of special interest to you.

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Please briefly describe any personal experiences, work experiences, education or training that are related to your interest in being an advisor.

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We are interested in connecting with our local communities. Please list any organizations or committees which you are involved in.

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Our goal is to create a diverse Advisory Panel. If you feel that you are able to represent the perspective of a group of people who may not typically be heard, please tell us about that perspective.

For example, we hope to engage people who are from diverse ethnic, racial, spiritual, social, economic, educational, and geographic backgrounds. We are also looking for people who are diverse in terms of gender, sexual orientation, family structure, disability, illness, and other characteristics.

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If you are not selected for this Panel can we keep your name for future openings on panels for research?

Yes

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