PSPA Expression of Interest in Research Form

You are completing this form because you are interested in either:

Receiving information and knowledge about research provided and disseminated: you are consenting to receiving research information and updates. This is called 'Engagement'.

Being a participant in a research study. You are consenting to your details being shared with study coordinators and being contacted for participating in studies. This is called 'Participation'. For Carers and family members, being a participant as a healthy control may mean you receive a 'dummy pill' or take part in testing.

Being involved with PSPA research activities providing support to researchers and research organisations (identifying priorities, commenting on materials, etc.) This is called 'Involvement'.

If you live in the United Kingdom, please complete the form below. However, if you live outside the United Kingdom and would like to express an interest in research or you are having difficulty completing this form, please email research@pspassociation.org.uk

I consent to have my details stored on PSPA's database and passed on to a researcher for participation in a study.

First Name

Last Name

House Number & Street Address

Town / City

County

Postcode

Email Address

Mobile Number

Home Phone

Preferred Phone

Gender

Pronouns

Ethnicity

Date of Birth

Date of Diagnosis

How did you hear about PSPA

Introduction From

I have been diagnosed with:

Research Opportunities

Below outlines the options available for you to take part in PSPA research.
Please select all that apply.

Engagement: you are consenting to receiving research information and updates

Participation: you are consenting to your details being shared with study coordinators and being contacted for participating in studies

Involvement: you are consenting to being involved in research activities supported by PSPA (identifying priorities, commenting on materials, etc.)

Have you taken part in any research previously?

If yes, what study were you involved with?

Communication Preferences

We would like to continue to keep in touch with you to tell you about the vital work we do for people with PSP or CBD, our fundraising activities, and opportunities to support us, as well as the services we provide.

Please select all the ways you would like to be contacted:

I would like to receive communications by email

I would like to receive communications by post

I would like to be contacted by phone

I would like contact from PSPA's support staff e.g. a Helpline Care Navigator

I do not wish to be contacted by PSPA

We will never sell your data and we promise to keep your details safe and secure. You can read our privacy statement here.

You can change your marketing options at any time by contacting us by email: consent@pspassociation.org.uk; telephoning us on 01327 322 410; or writing to us at PSPA, Margaret Powell House, 415a Midsummer Boulevard, Milton Keynes, MK9 3BN.

Registered charity number England and Wales 1037087 and Scotland SCO41199

Contact Information