Research Oversight Committee – Patient Partner

1) Name *

First

Last

2) Do you live in British Columbia? *

Patients must live in BC for this study

3) Town/city where you live *

4) Email *

5) Phone number: *

6) Have you been diagnosed with major depressive disorder? *

Please note this study is only for those with MDD.

7) Have you been diagnosed with any other mood disorder (such as bipolar disorder, mania, or dysthymia)? *

7a) Which other mental health condition(s) have you been diagnosed with? *

7b) Is your main diagnosis major depressive disorder? *

This means it is the main and most serious mental health condition you have been treated for if you have more than one mental health condition.

Please note this study is only for those with MDD.

8) Have you been diagnosed with an anxiety disorder (such as a phobia, obsessive compulsive disorder, or a panic disorder)? *

8a) Is your main diagnosis major depressive disorder? *

This means it is the main and most serious mental health condition you have been treated for if you have more than one mental health condition.

Please note this study is only for those with MDD.

9) Have you ever taken an antidepressant medication prescribed by a doctor? *

Please note this study is only for those with previous experience taking antidepressants.

9a) How many different kinds of prescribed antidepressant medications have you tried? *

10) Are you currently taking an antidepressant medication prescribed by a doctor? *

10a) Please tell us which one(s): *

11) Have you ever had a “pharmacogenomic test” (a test to look at your genetic information to determine which medication might work best for you) to treat depression? *

12) 12) Please let us know why you are interested in becoming a Patient Partner for this Research Oversight Committee. *

13) Please describe any current or previous experience/involvement with research or with a research funding organization (if any). *

14) Your age (Years)

Selected Value: 0

15) Gender: *

16) You may belong to one or more racial or cultural groups on the following list. Are you... ? (check all that apply) *

European origins
Chinese
Aboriginal (First Nations, Métis, or Inuit)
South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)
African origins
Filipino
Latin American
Southeast Asian (e.g., Cambodian, Indonesian, Laotian, Vietnamese, etc.)
Arab
West Asian (e.g., Afghan, Iranian)
Japanese
Korean
Other

16a) please specify:

17) What is your highest level of education? *

Completed elementary/junior school
High school (secondary school) diploma or certificate
Trade certificate or diploma from a vocational school or apprenticeship trainin
Non-university certificate or diploma from a community college, CEGEP, school of nursing, etc.
University certificate below bachelor’s level
Bachelor’s degree or teacher’s college (e.g., B.A., B.A. (Hons.), B.Sc., B.Ed.)
University degree or certificate above bachelor’s degree (e.g., M.A., M.Sc., M.B.A., M.D., Ph.D.)
Other

17a) please specify:

18) Last week, was your main activity working at a paid job or business, looking for paid work, going to school, caring for children, household work, retired or something else? *

Working at a paid job or business
Vacation (from paid work)
Looking for paid work
Going to school (including vacation from school)
Caring for children
Household work
Retired
Maternity/paternity leave
Long-term illness
Volunteering
Care-giving other than for children
Other

18a) please specify:

19) Are you able to access email at least once a week? *

20) Do you feel confident with reading and writing in English? *

21) Are you able to attend a 3-4 hour meeting twice per year during regular business hours (between 9am-5pm)? Meetings will be either by videoconferencing or in person at the offices of Genome BC in Vancouver, BC. Reimbursement will be provided for any travel/meals/accommodation related to attending in person meetings. *

22) Please let us know if there is anything else you want to add: