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:
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Yes
No
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Yes
No
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If no, please provide information for service location:
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2. |
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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
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3a. |
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3b. |
Yes
No
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Yes
No
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4. |
What specific training or professional experience do you have in cancer
genetics? Please include information about all of the following that apply:
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5. |
Yes
No
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6. |
For which of the following do you or members of your team provide expertise in
relation to cancer genetics:
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7. |
Yes
No
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8. |
Yes
No
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9. |
Yes,
No
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10. |
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11. |
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
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12. |
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.
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13. |
Please click the Submit button to return the completed form. Forms can also be
faxed to 301-402-6728 or mailed to:
PDQ Genetics Directory Coordinator
National Cancer Institute
Cancer Information Products and Systems
6116 Executive Blvd., Suite 3002B, MSC-8321
Bethesda, MD 20892-8321
ATTN: CIAT
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