A directory of individuals who provide services related to cancer genetics,
including cancer risk assessment, genetic counseling, genetic susceptibility
testing, and other services.
The criteria for inclusion in the directory are listed on the last page of this
application form. Please read them carefully before filling out the
application. For more information, please see the full description of the
directory.
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 list them on a separate sheet (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.)
-
____ 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:
-
_____ 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 _____ No
8. Are you willing to accept calls or email from individuals seeking familial
cancer risk counseling and/or genetic susceptibility testing?
-
_____ Yes _____ No
9. 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 specify the familial cancer-predisposing syndromes for which
professional services are provided. A list of cancer sites and types associated
with each syndrome will also be provided for searching in the directory.
_____ Adenomatous polyposis |
_____ Multiple endocrine neoplasia 1 |
_____ Ataxia-telangiectasia |
_____ Multiple endocrine neoplasia 2 |
_____ Basal cell nevus |
_____ Neurofibromatosis 1 |
_____ Bloom syndrome |
_____ Neurofibromatosis 2 |
_____ Breast/ovarian (BRCA1) |
_____ Osteochondromatosis |
_____ Breast/other (BRCA2) |
_____ Pancreatic cancer, familial |
_____ Carcinoid, familial |
_____ Paraganglioma, familial |
_____ Carney syndrome |
_____ Peutz-Jeghers syndrome |
_____ Chordoma |
_____ Prostate cancer, familial |
_____ Colon (HNPCC) |
_____ Renal cancer, familial |
_____ Cowden syndrome |
_____ Retinoblastoma |
_____ Esophagus, with tylosis |
_____ Rothmund-Thomson syndrome |
_____ Fanconi's anemia |
_____ Testicular carcinoma, familial |
_____ Gastric cancer, familial |
_____ Tuberous sclerosis |
_____ Hodgkin's disease |
_____ Von Hippel-Lindau syndrome |
_____ Li-Fraumeni syndrome
|
_____ Werner's syndrome |
_____ Melanoma |
_____ Wilms' tumor |
|
_____ Xeroderma pigmentosum |
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)
-
_____ 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 indicate how you would prefer to update your listing annually:
-
____ Email ____ Mail
-
Upon inclusion in the database, you will receive a request to verify the
information prior to release on Cancer.gov. Please review the listing and
respond immediately to ensure that your information is added to Cancer.gov in a
timely manner. Subsequent to this initial request for verification, you will
receive a verification request by email or mail once a year.
13. Please sign and date below:
-
Print name:
-
SIGNATURE:
-
DATE: ___________________________
Thank you for your interest in the NCI Cancer Genetics Services Directory.
Please fax this form to 301-402-6728 or mail to:
-
PDQ Genetics Directory Coordinator
ATTN: CIAT
National Cancer Institute
Cancer Information Products and Systems
6116 Executive Blvd., Suite 3002B, MSC-8321
Bethesda, MD 20892-8321
1. Licensed, board certified, or board eligible in their profession.
2. A member of one of the following professional organizations or special
interest groups:
-
American College of Medical Genetics (ACMG)
-
American Psychological Association
-
American Society of Clinical Oncology (ASCO)
-
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
3. Specific training or professional experience in cancer genetics. This could
include:
-
Publications authored
-
Courses taken
-
Years of experience
-
Number of patients counseled per year about genetic susceptibility to cancer
-
Investigator or research professional on genetics clinical trials
-
Clinical preceptorships taken
4. A member of or affiliated with an interdisciplinary team with substantial
expertise in cancer genetics. Members of the team should be able to provide the
following expertise in relation to cancer genetics:
-
Patient genetics education
-
Patient cancer-risk assessment
-
Appropriate pre- and post-test counseling and informed consent (including
ethical, legal, and 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)
5. Willing to accept referrals.
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