Your Contact Information

Your Name:

Your Email:

(Example: username@mail.nih.gov)

Phone:

(Example: 5-1212 or 301-555-1212)

Fax:

(Example: 5-1212 or 301-555-1212)

Division:

(Example: DCCPS, Office of Tobacco Use)

Activity Description

Please specify how many actual CARRA member names you will need to participate in your activity.
CARRA recommends that you include 1 advocate for every 10 non-advocates participating.

*Remember that CARRA program staff will provide you with several CARRA member names for each advocate actually needed.

Please give a brief description of your activity that includes the following:

• Title of your Activity

• Date(s)

• Location (is travel required?)*
  * Please remember that travel must be paid for by the requesting department.
  

• A general description of CARRA members duties

• Overall time commitment for a CARRA member

• Other types of people participating in the activity/meeting (i.e. scientists, researchers, physicians, other government employees, media, etc.)

• Resources you can provide to support CARRA members (i.e. background materials, travel expenses, etc.)

All CARRA members are either a(n):

• Cancer survivor

• First-degree family member or life partner

• Individual with more than 3 years of substantial, demonstrated involvement in cancer-related activities

In addition, all CARRA members have met the following requirements:

• Interest in learning about cancer, familiarity with cancer and science-related issues, or formal training in these areas

• Membership in a cancer-related group or organization

• Leadership qualities

• Writing skills and ability to make oral presentations

• Ability to work as both a team player and a self-starter

• Ability to represent the perspective of a group

• Ability to evaluate and understand cancer issues beyond their own cancer experience

• Interest in extending their personal knowledge about cancer and cancer issues

• Ability to speak, read, write, and understand English

Please describe any additional skills or experience that you would like a CARRA member to have for your activity. Examples include the following:

• Race, ethnicity, gender, geographic location, or other demographic characteristics

• Cancer site-specific experience

We will make every effort to find an advocate that best suits your needs.

Please list any potential conflicts of interest.