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:

Publish your email address in the NCI Cancer Genetics Services Directory? _____ Yes _____ No

Web site URL: _________________________________________

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):

3a. What is/are your specialties?

3b. Are you board certified in your specialty? _____ Yes _____ No

If yes, please specify specialty board:

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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.

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:  

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SIGNATURE:  

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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

NCI CANCER GENETICS SERVICES DIRECTORY CRITERIA FOR INCLUSION

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

• 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

• 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)

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