PAB Form - Precision Health Initiative

Personal and contact details

Address:

YOUR EXPERIENCE WITH GENOMIC RESEARCH

Have you taken part in a Genuity Science (formerly known as Genomics Medicine Ireland / GMI) study? If Yes, please indicate the study you participated in and, if applicable, the related disease area?

Yes No

GenoFit study

BrainFit study

Disease study

If you have not taken part in a Genuity study and are applying as you, or a close family member, are affected by a genetic condition or have participated in genetic research, please tell us what it is about your experience as a patient, or carer, that has made you want to apply for this role?

Additional Information

Please provide any other reasons why you are interested in participating in the Genuity PAB

What skills, past experiences or insights do you feel you can bring to the PAB?

What is your understanding of genomic research and the work of Genuity Science? Please note Genuity Science will provide education and training for all PAB members

Are you currently, or have you been involved in a Patient Advocacy group?

Yes No

If yes, please provide the full name of the organisation and the disease areas covered by the organisation:

Are you or have you been involved in other similar patient advisory roles, peer support groups, etc.? If yes please give details below

Yes No

Meetings

Due to Covid-19 restrictions initial meetings will be virtual. Future face-to-face meetings will be held in Dublin at Genuity’s office located in Cherrywood, Dublin 18.

Are you able to take part in meetings during office hours (usually between 9am and 5pm)?

Yes No

Are you able to take part in meetings outside office hours (weekday evenings between 5 and 9pm)?

Yes No

References

Please provide us with two references. Your referee should be someone who can comment on your suitability and experience/skills related to the role. Genuity Science may contact the referees you provide. Please include the name, job title, address, telephone number and email address of both of your referees.

Reference 1:

Reference 2:

Data Protection:

A privacy notice specific to this forum is attached below. If you have a question or concern about how we process your data, you can contact us at dataprivacy@genuitysci.com

Do you consent to the processing of your personal data by Genuity for the purposes of this Participant Advisory Board application?

Yes No

Genuity Science (Ireland) Ltd., Participant Advisory Board (PAB) Expression of Interest

Personal and contact details

YOUR EXPERIENCE WITH GENOMIC RESEARCH

Additional Information

Meetings

References

Data Protection: