Application Form

This content was archived on June 24, 2013.

Table of Contents

• Eligibility
• Privacy Notice
• Application Form
• Section A: Contact Information
• Section B: Demographic Information
• Section C: Interests
• Section D: Funding Affiliations and Experience Eligibility

Eligibility

Patient and Consumer Participation Pool
Health Products and Food Branch (HPFB)

Before completing the Application Form, it is mandatory to answer the following questions:

Are you:

1. 18 years of age or older and a Canadian citizen, Landed Immigrant or Permanent Resident of Canada?
   • Yes
   • No
2. Willing to commit to the Patient and Consumer Participation Pool for 2 years?
   • Yes
   • No
3. A current employee in the federal government's Health Portfolio or related agency¹?
   • Yes
   • No
4. A current elected official at a federal or provincial level?
   • Yes
   • No

Regrettably, if you answered no to questions a or b or yes to questions c or d, you are not eligible to join the Pool at this time. Do not complete the application form.

Please contact the Pool Secretariat at 613-948-8923 with any questions you may have regarding eligibility for the Pool.

Privacy Notice

Provision of the information requested on this form is voluntary.

The personal information requested in this report is collected under the authority of the Department of Health Act, the Food and Drugs Act, and the Food and Drugs Regulationsfor the purpose of establishing a pool of individuals whose input will be solicited by Health Products and Food (HPFB) programs on a range of health products and food related consultations. Failure to provide the personal information requested may affect Health Canada's ability to match Pool participants with HPFB programs seeking individuals for consultations.

Personal information that you provide is protected under the provisions of the  Privacy Act. The Privacy Act gives you the right to access and/or to correct your personal information. If you require clarification about this statement, contact our Access to Information and Privacy Coordinator at 613-954-9165 or e-mail atip-aiprp@hc-sc.gc.ca.

Application Form

If you have any questions regarding the Application Form, please refer to the eligibility and application information on the web site.

Section A - Contact Information

1) Contact information

• Prefix
  • Mr.
  • Mrs.
  • Ms.
  • Miss
• First Name
• Last Name
• Telephone Number
• City
• Province
• E-mail address

Section B - Demographic Information

2) What is your age? (select one)

• 18-24
• 25-30
• 31-44
• 45-64
• 65-79
• 80+

3) What is your gender?

• Male
• Female
• Other (please specify)

4) Where do you trace your origins back to: (please select all that apply)

• North America (Aboriginal)
• Africa
• Caribbean
• Central and South America
• East Asia
• South-East Asia
• West-Asia
• Western Europe
• Eastern Europe
• Middle East
• Oceania (including Australia and New Zealand)
• Other (please specific)

5) If you indicated Aboriginal origins in the previous question, please select all that apply:

• Status First Nations
• Non-Status First Nations
• Inuit
• Métis
• Other (please specify)

6) Which of the following categories best describes your total household income? That is, the total income of all persons in your household combined before taxes? (select one)

• Under $20,000
• $20,000 to $39,999
• $40,000 to $59,999
• $60,000 to $79,999
• $80,000 to $99,999
• $100,000 to $149,999
• $150,000 and over

7) What size of community do you live in? (select one)

• Rural (population less than 1,000)

  If rural, is the community "remote" (i.e. do you live more than 80 km from either a major regional hospital or an urban centre with a population of at least 50,000)?

  • Yes
  • No
  
  
• Small town (1,000 to 29,999 people)

  If small town, is the town "remote" (see definition above)?

  • Yes
  • No
  
  
• Small city (30,000 - 99,999 people)
• Mid-sized city (100,000 - one million people)
• Large urban centre (over one million people)

8) What is the highest level of schooling/education you have completed? (select only one)

• Public or elementary school
• Some High School
• High school certificate or equivalent
• Some College, CEGEP or other non-university institution
• College, CEGEP or other non-university certificate or diploma
• Some university
• Undergraduate university degree
• Post Graduate university degree
• Degree in health or medical related field

9) Language - spoken most often at home: (select one)

• English
• French
• Other (please specify)

Fluent in: (select all that apply)

• English
• French
• Other(s) (please specify)

10) Limitations

Are there considerations that might limit your ability to participate in certain types of consultations e.g. limited computer or internet access, physical or geographic considerations that might limit travel, able to commit to a limited amount of time for a consultation, etc.?

• Yes (please specify)
• No

11) Do you have access to high-speed internet?

• Yes
• No

Section C - Interests

12) Specific areas of interest within the mandate of the Health Products and Food Branch:

1. Please select the areas that you would be interested in, and have personal experience with: (Select all that apply)
   • Food Safety and Nutrition
   • Health Products and Drugs (for example, pharmaceutical drugs, medical devices, natural health products, etc.)
2. If you indicated interest and experience in food safety and nutrition, which issues do you have particular interest and experience in? (Select all that apply)
   • Chemical Contaminants (for example, mercury, acrylamide, dioxins)
   • Microbial Hazards (for example, Listeria, E.coli, Salmonella)
   • Food Safety Assessment
   • Food Policy Integration
   • Food Regulatory Modernisation
   • Nutritional Sciences
   • Promotion of Healthy Eating
   • Nutrition education (including nutrition labelling education and nutrition literacy)
   • Novel Foods (for example, Genetically Modified Foods)
   • Food Additives (for example, aspartame, caffeine)
   • Food Allergies (for example, Food Allergen Labelling, Celiac Disease)
   • Food Packaging (for example, Bisphenol A)
   • Food Fortification
   • Sodium Reduction Initiatives
   • Veterinary drugs
   • Labelling and Marketing of Foods (Health Claims)
   • Nutrition policy and guidance
   • Nutrition evaluation and surveillance
   • Creating supportive nutrition environments
   • Other (please specify)
   • All of the above
3. If you indicated interest and experience in health products and drugs, which issues do you have particular interest and experience in? (Select all that apply)
   • Prescription drugs
   • Non-prescription drugs (for example, antihistamines)
   • Natural health products (for example, vitamins and minerals, herbal remedies and homeopathic and traditional medicines)
   • Veterinary drugs
   • Biologics (for example, vaccines or insulin, cells, tissues and organs)
   • Radiopharmaceuticals (for the diagnosis and treatment of cancers and other health conditions)
   • Medical devices (for example, hearing aids or syringes)
   • Access to drugs
   • Clinical trials
   • Health product safety/adverse reactions
   • Compliance and enforcement
   • Labelling or product information
   • Special Access Program
   • Other (please specify)

13) Which, if any, health conditions do you have particular interest in? (Select all that apply)

• Addiction (for example, alcohol, drugs, nicotine etc.)
• Allergies (for example, food allergies, allergy testing etc.)
•  Auto-immune conditions (for example, Lupus, AIDS, etc.)
•  Bacterial infections (for example, tuberculosis, whooping cough, etc.)
• Blood disorders (for example, bleeding disorders, platelet disorders, hemophilia, anemia, etc.)
• Bones and joints (for example, arthritis, osteoporosis, etc.)
• Brain and nervous system (for example, seizures/Alzheimer's etc.)
• Cancer (for example, breast cancer, prostate cancer, etc.)
• Cardiovascular health and/or conditions/diseases (for example, Coronary Artery Disease, Atherosclerosis, etc.)
• Endocrine system and metabolic disorders (for example, thyroid, diabetes, obesity etc.)
• Environmental illness (for example, multiple chemical sensitivities)
• Eye (for example, glaucoma, macular degeneration etc.)
• Geriatrics/diseases of the elderly (for example, Alzheimer's, dementia, etc.)
• Heart and blood vessel diseases (for example, stroke/blood clots/high blood pressure etc.)
• Infectious diseases (for example, small pox, hepatitis etc.)
• Lung (for example, asthma, emphysema, Chronic Obstructive Pulmonary Disease (COPD), etc.)
• Mental health (for example, anxiety, depression, schizophrenia, etc.)
• Nerve conditions (for example, Multiple Sclerosis, etc.)
•  Nutritional (for example, deficiencies, celiac disease, etc.)
• Pain (for example, fibromyalgia, etc.)
•  Parasitic infections (for example, malaria, typhoid fever etc.)
• Pediatric (for example, infant, child and youth) illnesses, conditions and/or diseases (ADHD, Autism, FAS/FAE, etc.)
• Pregnancy-related conditions (for example,  gestational diabetes,  preeclampsia, interactions with chronic illnesses, and post-partum complications, etc.)
• Rare diseases (please specify)
• Sexual health and/or diseases (for example, Chlamydia, etc.)
• Stomach and intestinal diseases (for example, ulcers/Crohn's disease etc.)
• Vaccines (for example, tetanus etc.)
• Women's health issues (for example, pregnancy, reproductive health, breast, etc.)
• Other (please list)
• None

14) Types of Involvement

Which types of consultations are you willing to participate in? Please indicate:

• Web-Based/online
• Face-to-face, for example local roundtables
• Mail-in
• Phone
• External Advisory Committee

To be invited to participate on an External Advisory Committee, members have to be security cleared.

Do you already have a valid government of Canada security clearance?

• Yes
• No

If you do not have a current government of Canada security clearance, would you be willing to obtain one?

• Yes
• No

Section D - Funding Affiliations and Experience (Required)

15) Funding Affiliations

1. Have you received any funding from a business, industry or organization regulated by Health Canada (see Question 12 b and c) (such as salary, grants, payment of travel or other expenses, etc.) or other benefits (such as materials, discounted products, gifts, etc.) or engaged in agreements or negotiations for such funding or benefits within the last 5 years?
   • Yes
   • No
2. Do you have any investments, partnerships, equity, royalties, joint ventures, stocks or bonds related to a business, industry or organization regulated by Health Canada?
   • Yes
   • No
3. Is any organization where you are a decision maker, board member, staff member or volunteer, in the process of negotiating a grant or other funding from a business, industry or organization regulated by Health Canada or has received a grant or other funding in the past 5 years?
   • Yes
   • No

If your funding situation changes during the time you are a member of the Pool, you are required to update your information with the Pool Secretariat. Please note that at the time you participate in any Branch consultations, you may be required to provide information about your specific financial interests.

16) Professional or volunteer experience related to health products and/or food (complete for all organizations in which you have been involved or employed)

Organization/Company Name

Involved now
Active in the past

Service Area (select all that apply)

• Local
• Provincial/territorial
• National
• International

Your Role(s) (select all that apply)

• Decision-maker (Board member or senior staff)
• Staff
• Regular member
• Volunteer
• Other (specify)

17) How did you hear about the Pool?

• Colleague, friend or family
• Non-government organization
• Health Canada Website
• Other (please specify)

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