Application

Criteria for Inclusion

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 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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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.) 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 Ataxia-telangiectasia Basal cell nevus Bloom syndrome Breast/ovarian (BRCA1) Breast/other (BRCA2) Carcinoid, familial Carney syndrome Chordoma Colon (HNPCC) Cowden syndrome Esophagus, with tylosis Fanconi's anemia Gastric cancer, familial Hodgkin's disease Li-Fraumeni syndrome Melanoma Multiple endocrine neoplasia 1 Select All Multiple endocrine neoplasia 2 Neurofibromatosis 1 Neurofibromatosis 2 Osteochondromatosis Pancreatic cancer, familial Paraganglioma, familial Peutz-Jeghers syndrome Prostate cancer, familial Renal cancer, familial Retinoblastoma Rothmund-Thomson syndrome Testicular carcinoma, familial Tuberous sclerosis Von Hippel-Lindau syndrome Werner's syndrome 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 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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