Consumer Reviewer E-Nomination Form - US Too · 1. CURRENT RESUME\rA current resume is required in order to complete your nomination. A formal or informal resume is acceptable. \r
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Consumer Reviewer E-Nomination Form CSRA Confidential, 2017 Page 1 of 7
Consumer reviewers serve as lay experts on an injury, condition, and/or disease. They assess particular aspects of research applications focusing on the impact or relevance of the proposal. Consumer reviewers read and then provide written assessments on the impact of the proposed research and help to identify the applications that would best meet the research programs' goals to serve the individuals and affected communities.
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If you are a nominating or sponsoring organization, please provide this e-nomination form to your nominee, along with your letter of nomination/support.
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To be a consumer reviewer, you must
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· Be living with the disease, injury, or condition or be a family member or caregiver of a person living with a disease/injury/condition associated with a funded program. Consumer Reviewer Program Eligibility Requirements.
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· Be an active participant in an advocacy, outreach, or support organization in your local community and be nominated by your organization.
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· Have at least a high school education or its equivalent (higher education is not required).
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· Be fluent in listening, reading, speaking, and writing in English.
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· Have basic computer skills and have access to a computer with an Internet connection.
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· Have an interest in expanding your scientific knowledge about your disease or injury.
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· Represent the views of the affected community and not only your personal perspective.
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· If you are active duty military and applying for one of the military-focused programs, you will need to supply approval from your commanding officer. Contact us for further information.
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The Congressionally Directed Medical Research Programs (CDMRP) welcome patients, survivors, family members, and advocates to play a pivotal role in the future of biomedical research funding as consumer reviewers. To transform health care for our service members and the American public, the CDMRP looks to those who have the most experience and who understand the effects of a disease, an injury, or a condition.
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If you are a nominee, please verify that you are eligible to serve using the Consumer Reviewer Program Eligibility Requirements. Then complete this e-nomination form and submit it.
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If you have questions, please contact Gayle Sutch at [email protected] or call 240-236-9091.
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We appreciate your interest in this CDMRP service opportunity!
Directions: Save this form as LastName_FirstName, BEFORE and AFTER completing.
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PART I. NOMINEE AND SPONSOR INFORMATION
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Nominee Last Name:
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Nominee First Name:
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M.I.:
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Phone:
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Alt. Phone:
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Work Phone:
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Email Address:
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Address:
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City:
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State:
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Zip Code:
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Current Occupation:
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Highest Level of Education Attained:
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Military Service:
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Sponsoring or Nominating Organization:
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Sponsor's Name:
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Title:
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Address:
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City:
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State:
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Zip Code:
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Phone:
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Alt. Phone:
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Work Phone:
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Email Address:
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PROGRAM/SURVIVORSHIP: For which program are you eligible to serve as a consumer reviewer? (See Consumer Reviewer Program Eligibility Requirements)
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Are you a survivor/patient?
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Are you a family member of a survivor/patient? (see eligibility requirements)*
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OPTIONAL DEMOGRAPHIC INFORMATION:
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Birth Year:
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Yes
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No
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Yes
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No
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Ethnicity: (select one)
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If military, which branch?
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Rank:
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CSRA Confidential, 2017 Page 3 of 7
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PART II. PERSONAL STATEMENT ON ADVOCACY AND EDUCATION
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Directions: Answer each of the following questions as thoroughly as possible in a minimum of 4-6 sentences.
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Describe your role in the advocacy/support group that nominated you.
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Please provide a brief overview of your journey with your injury, condition, and/or disease.
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A.
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B.
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CSRA Confidential, 2017 Page 4 of 7
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C.
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How would you represent this group OR others with this illness, injury, or condition?
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How do you keep informed about issues or developments related to your condition/disease/injury and describe what resources you routinely use (eg, seminars, classes, journals, support groups, Internet, library)?
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D.
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CSRA Confidential, 2017 Page 5 of 7
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If you have served in peer review before, what was your experience and how do you feel it has benefited others?
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E.
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F.
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How would you evaluate a scientific proposal in which the research proposed challenged your ideas, values, and/or beliefs?
CSRA Confidential, 2017 Page 6 of 7
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COMPLETE the Consumer Reviewer E-Nomination Form.
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SAVE and PRINT a copy for your records.
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SUBMIT your e-nomination form by clicking the submit button at the end of this form
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SUBMISSION CHECKLIST
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PART III. OTHER REQUIRED ATTACHMENTS
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Directions: To ensure the integrity of your nomination form please save your attachments using the following format: LastName_FirstName_DocumentName. (eg, Resume or Nomination letter)
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1. CURRENT RESUME A current resume is required in order to complete your nomination. A formal or informal resume is acceptable.
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2. LETTER OF NOMINATION/SUPPORT A letter of nomination/support from your organization is required. Please identify if your letter will be
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sent by you
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sent directly from your nominating organization
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EMAIL required attachments identified in Part III.
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If you have any questions or require assistance completing this form, please contact Gayle Sutch, Consumer Reviewer Administrator Manager, at:
*These programs include various topic areas. Please visit http://cdmrp.army.mil for more information.
PROGRAM CONSUMER REVIEWER REQUIREMENTS - MUST BE
Alcohol & Substance Abuse Disorders Person living with or a family member of an individual with an alcohol and or substance
abuse disorder with a concurrent PTSD and/or TBI.
Amyotrophic Lateral Sclerosis (ALS) Person living with or family member of an individual with ALS.
Autism Person living with or family member of a person living with autism spectrum disorder.
Bone Marrow Failure Person living with the condition.
Breast Cancer Survivor of or person living with breast cancer.
Defense Medical Research and Development Program*
Person living with or family member/caregiver of a person living with a condition(s) directly relevant to military service such as posttraumatic stress disorder, traumatic brain injury, orthopaedic injuries, visual impairment, infectious diseases, and other conditions and ailments directly
relevant to battlefield injuries that affect service members, veterans, and their family members.
Duchenne Muscular Dystrophy (DMD) Person living with or a family member of a person living with DMD.
Epilepsy Person with military service living with, or family member/caregiver of a person living
with, posttraumatic epilepsy. Persons without military service may be considered.
Gulf War Illness Person living with Gulf War illness (veteran of Gulf War).
Lung Cancer Survivor of or person living with lung cancer.
Military Burn A survivor of traumatic burn injuries that were sustained in combat or combat-related activities.
Military service or Veteran preferred.
Multiple Sclerosis (MS) Person living with MS.
Neurofibromatosis (NF) Person living with or a family member of a person living with NF.
Orthopaedic Person living with an orthopaedic injury associated with military service—military or veteran.
Orthotics and Prosthetics Outcomes Research Program
Individuals living with a traumatic extremity injury as a result of military service resulting in limb impairment and/or limb loss, and who are using orthotic and/or prosthetic devices. The consumer reviewer may also be a health care provider such as a prosthetist, orthotist, physical therapist, occupational therapist, or other health care provider who works with extremity injury and understands the military and/or veteran
health care systems. Caregivers may also be considered.
Ovarian Cancer Survivor of or person living with ovarian cancer.
Parkinson’s Person living with or family member/caregiver of a person living with Parkinson's disease.
Peer Reviewed Alzheimer's Person with military service living with, or family member/caregiver of a person living with, Alzheimer's disease (AD) or mild cognitive
impairment (MCI). Persons without military service will be considered.
Peer Reviewed Cancer* Survivor of blood cancers, colorectal cancer, kidney cancer, melanoma and other skin cancers, mesothelioma, neuroblastoma, pancreatic
cancer, and other cancers (not including breast, prostate, ovarian or lung cancers). Additionally, an individual living with or a family member of pediatric brain tumor.
Peer Reviewed Medical* Person living with, survivor of, or family member of an individual living with the specific disease or condition.
Prostate Cancer Survivor of or person living with prostate cancer.
Psychological Health/Traumatic Brain Injury
Person living with or family member/caregiver of a person living with military service–associated psychological health challenges such as posttraumatic stress disorder and/or traumatic brain injury.
Reconstructive Transplant Research
Must be active duty service members or veterans who have sustained injuries or illnesses related to this topic area, such as injuries or illnesses resulting in amputation, disfigurement, or extreme loss of function. Priority will be given to individuals with service connected
conditions that are traumatic in nature. Veterans with non–service connected conditions or acquired malformations may also be considered if they have received treatment for the injury or illness in the military or Veterans Affairs health care systems.
Spinal Cord Injury Person living with or a family member/caregiver of a person living with a spinal cord injury associated with military service. Persons with
nonmilitary-related spinal cord injury will be considered.
Tick-Borne Disease Survivor of or person living with Lyme Disease or other tick-borne illnesses.
Tuberous Sclerosis Complex (TSC) Person living with or a family member of a person living with TSC.
Vision Research Program Person living with or a family member/caregiver of a person living with low vision or loss of sight associated with military service.
CSRA Confidential, 2017 Page 7 of 7
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CONSUMER REVIEWER PROGRAM ELIGIBILITY REQUIREMENTS
