CariGenetics X Daily Male Prostate Cancer Genetic Study Eligibility Form

Your participation in the CariGenetics X Daily Male Caribbean Prostate Cancer Genetic Study is a significant contribution to our mission of understanding the genetic differences in prostate cancer in men of Caribbean ancestry.

This study will include a select group of individuals - men with a history of prostate cancer and matched controls with no history of cancer or first-degree relatives (parents, siblings or children) with cancer. 

While our current research targets individuals with all four grandparents of Caribbean descent, this criteria does not exclude you from participating in our future research projects. 

If this opportunity resonates with you and you are interested in participating or would like to receive more information, please take a few moments to complete this form in its entirety below. 

The information you provide will help us determine your eligibility for the study and guide our research efforts. Once you submit the form, a member of the CariGenetics team will review your submission. 

If you meet the study criteria, we will contact you to discuss the next steps, which will include an initial interview and a meeting with our clinical staff. 

If you do not meet the study criteria right now, we will inform you via email. 

We appreciate your interest and your commitment to making a difference in the fight against prostate cancer. Together, we can make significant strides in prostate cancer research. 

Best Regards,

Dr. Carika Weldon
Study Lead Researcher
CariGenetics Limited
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Email *
Legal First Name *
Legal Middle Names *
Legal Last Names *
Date of Birth (DOB) *
Please note all persons interested in the study must be over the age of 18 years old. 
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Current Age *
Gender *
Primary Contact Number *
Country of Residence *
Are all four (4) of your grandparents of Caribbean descent.  *
This current pilot research study is for participants who have four (4) grandparents of Caribbean descent, however this does not exclude you from future research projects. 

Please note that being Bermudian is classified as Caribbean descent.
Please select the ethnicity(s) you identify as: *
Please tick all that apply (e.g. if you are of both African and Indian descent tick both boxes)
Required
If "Other" ethnicity: please describe
Please select the group you are eligible for. *
1. A history of prostate cancer (Patient Group)
2. NO history of cancer and NO first degree relative (eg. parent, sibling or child) with cancer (Control Group)
3. No history of cancer but has first degree relative (eg. parent, sibling or child) with cancer (Related Group)
If patient group, what was your age at diagnosis? *
If not, patient group add "N/A"
If patient group, what was the year of your diagnosis?
If not, patient group add "N/A"
If eligible, would you prefer a morning or afternoon consent interview? *
Click all that apply
Required
If eligible, would you prefer a specific date for your consent interview?
*
Click all that apply
Required
Do you have full insurance coverage (if not, we can take action to get coverage for follow up testing and treatment - For Bermuda only) *
If you had the option to own and monetise your genetic data in the future, would you take advantage of it?
*
This will be an opt-in option potentially made available in the future.
If you are not eligible for this study, do you give permission that we can re-contact you about other studies in the future? *
Required
How did you hear about this study? *
As a thank you for being in the study, all eligible participants will be given a FREE CariGenetics test kit. Which ONE of the following would you like for FREE?
*
If not eligible right now, we will send a discount code for registering your interest!
I hereby agree that all the information above is correct.  *
Required
Thank you for signing up to join the CariGenetics X Daily Male Caribbean Prostate Cancer Genetic Study! Your participation will make an historic impact on men's health in the Caribbean.
A copy of your responses will be emailed to the address you provided.
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