PCAB Application 2025 PCAB Application Thank you for your interest in serving on ZERO’s Patient & Caregiver Advisory Board (PCAB). Please review the PCAB role description before completing this application. This is a two-year volunteer role, starting in January 2026 and ending in December 2027. As a reminder, a patient/survivor and their caregiver (e.g., husband and wife, father and son) cannot both apply to be on the PCAB. This role requests availability to participate in 4-6 annual virtual meetings. Are you available to attend these virtually? Yes No This role requests the use of technology, computer, speakers, wireless internet, and/or phone during engagement. Yes No Your Name First Last Email Address Phone Number Address Address Address 2 City/Town State/Province - None -AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyomingFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPuerto RicoPalauVirgin IslandsArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces PacificBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code What is your primary connection to prostate cancer? [select one] What is your primary connection to prostate cancer? [select one] - Select -I am a prostate cancer patient/survivorI am a care partner/caregiver of someone with prostate cancerOther… Enter other… Please describe your/your loved one’s prostate cancer. [select all that apply] Currently in treatment for prostate cancer Currently in active surveillance Completed treatment within the last 5 years Completed treatment 5-10 years ago Completed treatment more than 10 years ago Experience a recurrence of prostate cancer after initial treatment Living with advanced/metastatic prostate cancer How did you first get involved with ZERO? Served as a Support Group Leader Served as a MENtor Attended a ZERO Run/Walk Served as an advocate (advocated at Summit, sent emails or called legislators) Raised funds for ZERO Other… Enter other… Which racial or ethnic group do you identify with? [select one] - Select -AsianBlack or African AmericanHispanic or LatinoMiddle Eastern or Alaska NativeNative Hawaiian or Pacific IslanderWithe or CaucasianMultiracial or BiracialA race/ethnicity not listed here Indicate if any of the following demographic or risk factor information applies to you (if you are a patient/survivor) or to your loved one (if you are a caregiver). [select all that apply] Veteran or Active Duty Military Personnel Family history of prostate cancer (father, brother, etc.) Known genetic mutation (BRCA 1, BRCA 2, etc.) Have a disability Identify as a member of the LGBTQIA+ community Ashkenazi Jewish heritage Please describe your experience with prostate cancer as a patient, survivor or caregiver. (up to 250 words). Please tell us why you are interested in serving on the ZERO PCAB (up to 500 words). This should include your motivation for joining, relevant experience, the perspective you would bring, specific areas of interest in patient support/education, and any special skills or expertise that you have. How comfortable are you with speaking in a group and sharing personal experiences? - Select -Very comfortableSomewhat comfortableNot comfortable How comfortable are you with giving respectful feedback in a group setting & listening to feedback from others? - Select -Very comfortableSomewhat comfortableNot comfortable By submitting this form, you agree to abide by ZERO’s Standards of Excellence
