The Hospital@Home Project Team thanks you for your interest in our project. Before completing this application form, please make sure you have carefully read the Call for Expressions of Interest.

Privacy Notice about your data: To consider your application as a patient advisor for the Hospital@Home Project, we have to collect personal data from you to evaluate your application and contact you. Should you be selected, we will store your contact information for the duration of the project (60 months). Should you not be selected, your data will be deleted within a month after the selection process is completed.

The data you provide will be processed by GHH under the General Data Protection Regulation (Regulation (EU) 2016/679). As such, you have the following rights with regards to the data you provide:
- Right of access – You have the right to request a copy of the Personal data that we hold about you.
- Right of correction – You have the right to correct Personal Data that we hold about you that is inaccurate or incomplete.
- Right to erase – You have the right to ask GHH to delete or remove Personal Data from our records
- Right to restrict – You have the right to restrict the processing of your Personal Data.
- Right to transfer – You have the right to have the Personal Data we hold about you transferred to another organisation.
- Right to object – You have the right to object to certain types of processing such as direct marketing, as well as processing we undertake based on our legitimate interests.

For our complete privacy policy, please read more about it here. Should you have any questions, comments or concerns for this survey or regarding your data please contact Global Heart Hub EU Projects Associate at valerie@globalhearthub.org.
Personal Information

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

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* 4. Permanent Address

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* 5. Email Address

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* 6. Please select which disease area you represent (multiple answers may apply)

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* 7. Gender

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* 8. Level of English

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* 9. What other languages do you speak?

Experience with health topics

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* 10. Do you have someone to help you read hospital or clinic materials?

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* 11. Do you find it challenging to learn about your medical condition because written information is difficult to understand?

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* 12. How confident are you filling out medical forms by yourself?

Experience with digital health technologies

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* 13. How confident are you using the internet or a smartphone to find health information?

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* 14. Do you have an understanding and/or experience with digital health technologies?

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* 15. Do you need help using digital tools (like patient portals, health apps, or online appointment systems) to manage your health?

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* 16. Have you or a family member ever used digital health technology (such as an external or implanted medical device, telehealth platforms, monitoring app, virtual care tools, etc.)?

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* 17. If yes, could you please specify the type of digital health technology device used? (Max. 100 words)

Experience as member of Patient Advisory Board for EU-funded projects

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* 18. Do you have any experience in participating in other Patient advisory Boards or Groups in any EU-funded projects?

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* 19. If your answer is yes, please briefly describe the project and your role in it (if this does not apply to you, please type N/A) (Max. 100 words)

Experience in patient networks

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* 20. Are you part of a broader network (e.g. patient organisation/group)?

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* 21. If your answer is yes, could you briefly describe which organisation/group and your involvement in it (if this does not apply to you, please type N/A) (Max. 100 words)

Motivation to apply

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* 22. Please tell us about why you are interested in joining the H@H Patient Advisory Board (Max. 500 words)

Conflict of Interest

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* 23. Do you have any actual or apparent conflict of interest to declare (e.g. direct affiliation with industry partners or regulatory authorities such as EMA)

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* 24. If yes, please briefly describe your potential conflict of interest (if this does not apply to you, please type N/A)

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* 25. I agree and sign the declaration of interest by checking the "yes" box below

Confirmation and Consent

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* 26. If I am selected, I will contribute to regular Patient Advisory Board meetings and other relevant meetings, and provide input and feedback to project consortium members where needed

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* 27. If I am selected, my participation will depend on the activities, topics, dates and relevance of the H@H project. Mandatory commitment of 4 yearly online meetings and possibly 2 ad-hoc meetings, including meeting pre-reading materials.

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* 28. I declare on my word of honour that the information provided above is true and complete. I understand that any misrepresentation in supplying this information may lead to my exclusion from the present call.

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* 29. Please attach your CV to your application (max 2 pages, PDF or MS Word)

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