MPNCEE 2018 Survey

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* 1. Your contact information

First name

Family Name

Address

City/Town

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. What is your profession?

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* 3. Are you working for a Melanoma advocacy group?

Name of the group

Country

Website

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* 4. Your relationship to Melanoma

	Stage 1	Stage 2	Stage 3	Stage 4	NED (no evidence of disease)	Not Applicable
I am a Melanoma patient	I am a Melanoma patient Stage 1	I am a Melanoma patient Stage 2	I am a Melanoma patient Stage 3	I am a Melanoma patient Stage 4	I am a Melanoma patient NED (no evidence of disease)	I am a Melanoma patient Not Applicable
I am the carer of a Melanoma patient whose disease is in	I am the carer of a Melanoma patient whose disease is in Stage 1	I am the carer of a Melanoma patient whose disease is in Stage 2	I am the carer of a Melanoma patient whose disease is in Stage 3	I am the carer of a Melanoma patient whose disease is in Stage 4	I am the carer of a Melanoma patient whose disease is in NED (no evidence of disease)	I am the carer of a Melanoma patient whose disease is in Not Applicable
I am a Melanoma Patient Advocate	I am a Melanoma Patient Advocate Stage 1	I am a Melanoma Patient Advocate Stage 2	I am a Melanoma Patient Advocate Stage 3	I am a Melanoma Patient Advocate Stage 4	I am a Melanoma Patient Advocate NED (no evidence of disease)	I am a Melanoma Patient Advocate Not Applicable
Other	Other Stage 1	Other Stage 2	Other Stage 3	Other Stage 4	Other NED (no evidence of disease)	Other Not Applicable

If other, please specify

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* 5. Your Melanoma is

Melanoma of the skin (cutaneous Melanoma)

Melanoma of the eye (ocular- uveal- choroidal Melanoma)

Melanoma that started on hand or feet (acral Melanoma)

Melanoma that started on the inner body surfaces (mucosal Melanoma)

Pediatric Melanoma

I don't know

does not apply

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* 6. What are the Melanoma Drugs presently available in your country? Please tick and/or comment.

	approved and available to every patient in need without restriction	approved but only available with certain restrictions- e.g. first line only, only 20 patients	approved but in reality, not available	not approved in my country	I don't know
Dabrafenib	Dabrafenib approved and available to every patient in need without restriction	Dabrafenib approved but only available with certain restrictions- e.g. first line only, only 20 patients	Dabrafenib approved but in reality, not available	Dabrafenib not approved in my country	Dabrafenib I don't know
Trametinib	Trametinib approved and available to every patient in need without restriction	Trametinib approved but only available with certain restrictions- e.g. first line only, only 20 patients	Trametinib approved but in reality, not available	Trametinib not approved in my country	Trametinib I don't know
Vemurafenib	Vemurafenib approved and available to every patient in need without restriction	Vemurafenib approved but only available with certain restrictions- e.g. first line only, only 20 patients	Vemurafenib approved but in reality, not available	Vemurafenib not approved in my country	Vemurafenib I don't know
Cobimetinib	Cobimetinib approved and available to every patient in need without restriction	Cobimetinib approved but only available with certain restrictions- e.g. first line only, only 20 patients	Cobimetinib approved but in reality, not available	Cobimetinib not approved in my country	Cobimetinib I don't know
Nivolumab	Nivolumab approved and available to every patient in need without restriction	Nivolumab approved but only available with certain restrictions- e.g. first line only, only 20 patients	Nivolumab approved but in reality, not available	Nivolumab not approved in my country	Nivolumab I don't know
Pembrolizumab	Pembrolizumab approved and available to every patient in need without restriction	Pembrolizumab approved but only available with certain restrictions- e.g. first line only, only 20 patients	Pembrolizumab approved but in reality, not available	Pembrolizumab not approved in my country	Pembrolizumab I don't know
Ipilimumab	Ipilimumab approved and available to every patient in need without restriction	Ipilimumab approved but only available with certain restrictions- e.g. first line only, only 20 patients	Ipilimumab approved but in reality, not available	Ipilimumab not approved in my country	Ipilimumab I don't know
T-VEC	T-VEC approved and available to every patient in need without restriction	T-VEC approved but only available with certain restrictions- e.g. first line only, only 20 patients	T-VEC approved but in reality, not available	T-VEC not approved in my country	T-VEC I don't know
Dabrafenib/Trametinib	Dabrafenib/Trametinib approved and available to every patient in need without restriction	Dabrafenib/Trametinib approved but only available with certain restrictions- e.g. first line only, only 20 patients	Dabrafenib/Trametinib approved but in reality, not available	Dabrafenib/Trametinib not approved in my country	Dabrafenib/Trametinib I don't know
Vemurafenib/Cobimetinib	Vemurafenib/Cobimetinib approved and available to every patient in need without restriction	Vemurafenib/Cobimetinib approved but only available with certain restrictions- e.g. first line only, only 20 patients	Vemurafenib/Cobimetinib approved but in reality, not available	Vemurafenib/Cobimetinib not approved in my country	Vemurafenib/Cobimetinib I don't know
Ipilimumab/Nivolumab	Ipilimumab/Nivolumab approved and available to every patient in need without restriction	Ipilimumab/Nivolumab approved but only available with certain restrictions- e.g. first line only, only 20 patients	Ipilimumab/Nivolumab approved but in reality, not available	Ipilimumab/Nivolumab not approved in my country	Ipilimumab/Nivolumab I don't know

Comments

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* 7. Tell us about yourself- what is your relationship with Melanoma? Are you already involved in patient advocacy?

Conference language will be EFL = English as foreign language. No need to be perfect- but you want to be able to follow and participate in the discussion! And no worry- most of us are non-native English speakers.

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* 8. How do you rate your English proficiency?

native speaker/ professional level

good

average

not so good

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* 9. You have attended

MPNE 2014 'The trials we want'

MPNE 2015 'The risk of not taking risks'

MPNE 2016 'Power to the patient'

MPNE 2017 'Value versus Affordability'

MPNCEE 2017 'Melanoma in CEE' 1st edition

MPNE 2018 'Melanoma at the Edge'

none of the above, first time at a MPNE conference!

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* 10. What do you hope to take home from this conference?

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* 11. Do you have a Melanoma project that you would like to present as POSTER at MPNCEE2018? Please add a short description here! All posters will be on display on Friday 21st September.

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* 12. Anything else you would like to let us know?

You will hear from us whether your application was successful.

Please do not book any travel before that. Reimbursement of travel will happen after full attendance of the conference and against original travel receipts.

We will continuously update the conference information on our website here

By submitting your application, you agree for MPNE to hold your personal data for the purpose of the organization of this conference only and anonymised data (like number of patients attending a certain conference, countries of origin of participants) for MPNE's documentation of activities and general work.

We are looking forward to meeting you in Bucharest!
The MPNE team