HEPATITIS D GLOBAL COMMUNITY ADVISORY BOARD (HDV-CAB)
APPLICATION FOR MEMBERSHIP

Application Deadline: Thursday, April 14, 2022

The Hepatitis B Foundation and Hepatitis Delta Connect are pleased to announce a new initiative to integrate community perspectives and experiences into hepatitis D (HDV) drug development and clinical research to ensure that the voices of those living with HDV are represented and centered in decision-making by industry, governments, and nonprofits. The first step in this endeavor is the creation of an HDV Global Community Advisory Board (HDV-CAB), which will consist of 8-12 individuals who are living with or affected by HDV (including family members and caregivers).

We encourage you to review the HDV-CAB Charter before starting your application.

We are also currently recruiting members for a separate CAB focused on Hepatitis B. If you are interested in the HBV CAB, please use this application form instead.

Note: The official language of the HDV-CAB is English. Since members are expected to contribute to the HDV-CAB and participate in discussions, fluency in English is essential for membership.

Please email info@hepb.org with any questions.

Personal Information

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* 1. Last (Family) Name

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* 2. First Name

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* 3. Country of Residence

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* 4. Phone Number - Provide at least one phone number where we can reach you. Please include the international access code + area code + number.

Mobile Phone:

Home Phone:

Office Phone:

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* 5. Personal Email Address:

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* 6. Profession/Occupation/Current Job/Volunteer Affiliation(s)

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* 7. Age - This question is optional.

18-24

25-34

35-44

45-54

55-64

65+

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* 8. Gender Identity - This question is optional.

Female

Male

Transgender

Gender diverse or non-binary

Prefer not to say

Prefer to self-describe:

Experience with HDV

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* 9. Please list the name and location of any hepatitis organizations you are affiliated with, whether as an employee or volunteer. You may also provide references from the organization(s) if you wish (name and email address), but this is not required.

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* 10. What type of work do you do at your affiliated organization(s) and/or independently? (Check all that apply.)

Patient or community education/awareness

Health and/or social service provider

Advocacy

Other (please specify)

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* 11. Have you ever been involved in hepatitis B or D advocacy? If yes, please state when and why you became involved in this work.

Examples of advocacy include:
-Reaching out to elected officials/government leaders in your country (through in-person meetings, phone calls, emails, or letters) to request funding, policies, or programs to address hepatitis B and/or D
-Participating in a group advocacy day or event in your country
-Coordinating or signing petitions or campaigns to address issues faced by people living with hepatitis B and/or D

Knowledge of HBV and HDV

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* 12. Rate your level of knowledge in each of the following categories:

	None or very little	Basic	Good	Very good
Issues faced by HBV and HDV patients	Issues faced by HBV and HDV patients None or very little	Issues faced by HBV and HDV patients Basic	Issues faced by HBV and HDV patients Good	Issues faced by HBV and HDV patients Very good
HDV treatment in general	HDV treatment in general None or very little	HDV treatment in general Basic	HDV treatment in general Good	HDV treatment in general Very good
Process for approval of new medicines in your country	Process for approval of new medicines in your country None or very little	Process for approval of new medicines in your country Basic	Process for approval of new medicines in your country Good	Process for approval of new medicines in your country Very good
Clinical trial process	Clinical trial process None or very little	Clinical trial process Basic	Clinical trial process Good	Clinical trial process Very good

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* 13. Please list any additional knowledge/expertise/skills (pediatric, women, cirrhosis, transplant, HIV/HBV/HDV coinfection etc.) that you would bring to the HDV-CAB.

Interest in HDV

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* 14. Why are you interested in becoming a member of the HDV-CAB? (Please limit your response to 200 words or less.)

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* 15. Every HDV-CAB member agrees to contribute to the overall duties of the group. Please indicate the type of work you are interested in and can commit to within the HDV-CAB by rating each on a scale of 1 (least amount of interest) to 4 (most amount of interest).

	1	2	3	4
Providing logistical support and coordination with HDV-CAB meeting coordinator	Providing logistical support and coordination with HDV-CAB meeting coordinator 1	Providing logistical support and coordination with HDV-CAB meeting coordinator 2	Providing logistical support and coordination with HDV-CAB meeting coordinator 3	Providing logistical support and coordination with HDV-CAB meeting coordinator 4
Working with the group and industry, nonprofit, and governmental partners to draft meeting agendas	Working with the group and industry, nonprofit, and governmental partners to draft meeting agendas 1	Working with the group and industry, nonprofit, and governmental partners to draft meeting agendas 2	Working with the group and industry, nonprofit, and governmental partners to draft meeting agendas 3	Working with the group and industry, nonprofit, and governmental partners to draft meeting agendas 4
Taking notes at external meetings (with industry, nonprofit, and governmental partners) and co-developing follow-up letters outlining important issues raised during meetings	Taking notes at external meetings (with industry, nonprofit, and governmental partners) and co-developing follow-up letters outlining important issues raised during meetings 1	Taking notes at external meetings (with industry, nonprofit, and governmental partners) and co-developing follow-up letters outlining important issues raised during meetings 2	Taking notes at external meetings (with industry, nonprofit, and governmental partners) and co-developing follow-up letters outlining important issues raised during meetings 3	Taking notes at external meetings (with industry, nonprofit, and governmental partners) and co-developing follow-up letters outlining important issues raised during meetings 4
Clinical trial protocol review	Clinical trial protocol review 1	Clinical trial protocol review 2	Clinical trial protocol review 3	Clinical trial protocol review 4

Acknowledgements

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* 16. Please read and acknowledge the following statements by checking the box next to each one before submitting this application:

I understand and agree that this application form will be reviewed by Hepatitis B Foundation staff and key partners.

I understand and agree that, if accepted as a member, information from this application form will be included in the HDV-CAB Membership database.

HEPATITIS D GLOBAL COMMUNITY ADVISORY BOARD (HDV-CAB)APPLICATION FOR MEMBERSHIP

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* 1. Last (Family) Name

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* 2. First Name

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* 3. Country of Residence

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* 4. Phone Number - Provide at least one phone number where we can reach you. Please include the international access code + area code + number.

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* 5. Personal Email Address:

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* 6. Profession/Occupation/Current Job/Volunteer Affiliation(s)

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* 7. Age - This question is optional.

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* 8. Gender Identity - This question is optional.

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* 9. Please list the name and location of any hepatitis organizations you are affiliated with, whether as an employee or volunteer. You may also provide references from the organization(s) if you wish (name and email address), but this is not required.

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* 10. What type of work do you do at your affiliated organization(s) and/or independently? (Check all that apply.)

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* 12. Rate your level of knowledge in each of the following categories:

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* 13. Please list any additional knowledge/expertise/skills (pediatric, women, cirrhosis, transplant, HIV/HBV/HDV coinfection etc.) that you would bring to the HDV-CAB.

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* 14. Why are you interested in becoming a member of the HDV-CAB? (Please limit your response to 200 words or less.)

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* 15. Every HDV-CAB member agrees to contribute to the overall duties of the group. Please indicate the type of work you are interested in and can commit to within the HDV-CAB by rating each on a scale of 1 (least amount of interest) to 4 (most amount of interest).

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* 16. Please read and acknowledge the following statements by checking the box next to each one before submitting this application:

HEPATITIS D GLOBAL COMMUNITY ADVISORY BOARD (HDV-CAB)
APPLICATION FOR MEMBERSHIP