Form 1 Application for Inclusion in NCI Cancer Genetics Service

Genetic Services Directory Join Form - National Cancer Institute

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Application for Inclusion in NCI Cancer Genetics Services Directory (PDQ®)
Application
OMB No. 0925-xxxx Expiry Date xx-xx-20xx
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this address.

1.

Please provide your full name, including middle initial, and the complete address, telephone number, fax number, and
email address where you can be contacted for annual verification of your information:
Name:
Institution:
Address:

Telephone Number:
Fax Number:
* Email Address:

Publish your email address in the NCI Cancer Genetics Services Directory?

Yes

No

Web site URL:
Do you provide services at this location?

Yes

No

If no, please provide information for service location:
Institution:
Address:

Telephone Number:
If you want additional locations, please enter them below (maximum of four):

2.

What type of health care professional are you?
Physician (M.D., D.O., or foreign equivalent)
Geneticist (Ph.D.)
Genetic Counselor (M.S., M.Sc., M.A.)
Nurse (R.N., B.S.N., M.S.N., Ph.D.)

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Clinical Social Worker (M.S.W., D.S.W.)
Clinical Psychologist (Ph.D.)
Other
Please specify degree(s):

Provide professional license and/or national certification number and state:

3a.

What is/are your specialties?

3b.

Are you board certified in your specialty?

Yes

No

If yes, please specify specialty board:
If no, are you board eligible?

Yes

No

If yes, please provide the year you became eligible:
4.

What specific training or professional experience do you have in cancer genetics? Please include information about all
of the following that apply:
Citations for relevant publications:

Examples of relevant continuing education or graduate courses:

Clinical preceptorships taken:

Investigator (or other research professional) on genetics clinical trials:

Number of patients counseled per year about genetic susceptibility to cancer:

Number of years of experience:

5.

Are you a member of or affiliated with an interdisciplinary team with substantial expertise in cancer genetics?

Yes

No
6.

For which of the following do you or members of your team provide expertise in relation to cancer genetics:

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Patient genetics education
Patient cancer risk assessment
Appropriate pre- and post-test counseling and informed consent (including ethical, legal, social issues related to testing and
disclosure of test results)
Genetic susceptibility testing (including information on limitations, specific tests available, and regulations concerning testing
procedures such as CLIA and CAP/ACMG)
Follow-up plan of care (including medical care, psychological support, and counseling about options for prevention or early
detection guidelines)

7.

Do you currently provide professional services to individuals or families seeking familial cancer risk counseling or
genetic susceptibility testing?
Yes

8.

Are you willing to accept calls or email from individuals seeking familial cancer risk counseling and/or genetic
susceptibility testing?
Yes

9.

No

No

Are there restrictions or limitations to services provided (i.e., a person must be eligible for a clinical trial in order to
receive services)?
Yes, Explain:
No

10.

Please verify the familial cancer predisposing syndromes for which you provide services. A list of cancer sites and
types associated with each syndrome will also be provided for searching in the directory.
Adenomatous polyposis, familial

Multiple endocrine neoplasia 2

Ataxia-telangiectasia

Neurofibromatosis 1

Basal cell nevus syndrome

Neurofibromatosis 2

Bloom syndrome

Osteochondromatosis

Breast/other (BRCA2)

Pancreatic cancer, familial

Breast/ovarian (BRCA1)

Paraganglioma, familial

Carcinoid syndrome, familial

Peutz-Jeghers syndrome

Carney syndrome

Prostate cancer, familial

Chordoma, familial

Renal cancer, familial

Colon (HNPCC)

Retinoblastoma, hereditary

Cowden syndrome

Rothmund-Thomson syndrome

Esophagus, with tylosis

Testicular carcinoma, familial

Fanconi anemia

Tuberous sclerosis complex

Gastric cancer, familial

Von Hippel-Lindau syndrome

Hodgkin lymphoma, hereditary

Werner syndrome

Li-Fraumeni syndrome

Wilms tumor, hereditary

Melanoma, hereditary

Xeroderma pigmentosum

Multiple endocrine neoplasia 1
Select All

11.

Please note your membership in any of the following national societies or special interest groups:
American College of Medical Genetics (ACMG)
American Psychological Association
American Society of Clinical Oncology (ASCO)

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American Society of Human Genetics (ASHG)
International Society of Nurses in Genetics (ISONG)
National Society of Genetic Counselors (NSGC)
NSGC Special Interest Group in Cancer
Oncology Nursing Society (ONS)
ONS Cancer Genetics Special Interest Group
12.

Please click the Submit button to complete your application.
We will process your application within a week and send you an email with a link to your listing on the Cancer.gov Web site. Please
review the listing and let us know if any changes need to be made. You will also receive a verification request by email once a year.
For more information about the directory or help with the application, please contact the Directory Coordinator at
[email protected].

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