Patient Summit Application
The National Viral Hepatitis Roundtable (NVHR) will be hosting a hepatitis C (HCV) patient summit July 29 and 30, 2019. The summit, NVHR’s first national patient gathering, will bring together 100 patients cured of or currently living with HCV with an emphasis on those who have not had experience engaging in other advocacy programs. The Patient Summit will be a starting point for growing a grassroots movement to better address HCV in the US and centering the voices of patients in hepatitis elimination planning efforts.

To ensure the diversity of attendees includes the entire patient population of the HCV epidemic, the patient summit will prioritize recruitment of individuals from across the entire patient community, including disproportionately impacted and marginalized communities representing all states. In order to attend the Patient Summit, we ask that you have received a diagnosis of hep C (whether currently living with or not) at some point in your life. Please provide as much of the information below as you are comfortable with in your application to participate in the Patient Summit. This very personal information is being asked to ensure full inclusion of perspectives and voices in the Summit and will not be shared outside of the planning committee.

NVHR will support travel expenses for accepted applicants.

The deadline for submitting the application is the end of the day on Sunday, May 19. You can mail a hard copy of the application to the address below:

Alyssa Kitlas
444 North Capitol St NW Suite 339
Washington, DC 20001

Name (First and Last) *
Your answer
Age *
Your answer
How would you describe your gender identity? *
Your answer
How do you describe your race and ethnicity? *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
What state do you live in? *
Your answer
Do you reside in an area that is considered urban, suburban, or rural? *
Have you been diagnosed with chronic hepatitis C?
Year of Hepatitis C Diagnosis *
Your answer
Are you available to fly to Atlanta, GA on July 29 and 30, 2019 if all costs are covered?
Are you available to attend the full-day Summit on July 29 and 30, 2019 i f all costs are covered?
Are you willing to participate in at least 2 webinars/calls in summer 2019 and at least 2 webinars/calls after the Summit to prepare for the Summit and plan next steps to continue to be involved in hepatitis C advocacy?
Are you living with any additional medical conditions that you feel comfortable disclosing (e.g. hepatitis B, HIV, TB)?
Are you currently pregnant and/or have you had children since receiving your diagnosis?
Are you aware of how you contracted hepatitis C?
If yes, please feel free to describe if comfortable sharing:
Your answer
Do you currently use drugs? (We are asking for additional information to help us ensure a wide range of experiences are represented. Your current or past experience with drug use will not be shared and will not reduce your chances of being selected.)
Are you currently living with hepatitis C or have you been cured? If cured, please describe your treatment experience. *
Your answer
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