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NCI Cancer Genetics Services Directory: Application Form

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NCI Cancer Genetics Services Directory: Application Form

OMB No. 0925-0639 Expiry Date 08-31-2014
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 (0925-0639). 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:










If no, please provide information for service location:





2. * What type of health care professional are you?








3a. * What is/are your specialties? (Choose one or more)















3b. * Are you board certified in your specialty?  



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






5. * Are you a member of or affiliated with an interdisciplinary team with substantial expertise in cancer genetics?  
6. * For which of the following do you or members of your team provide expertise in relation to cancer genetics? (Choose one or more)




7. * Do you currently provide professional services to individuals or families seeking familial cancer risk counseling or genetic susceptibility testing? (Please note that if you do not provide services, you cannot be added to the directory.)
 
8. * Are you willing to accept calls or email from individuals seeking familial cancer risk counseling and/or genetic susceptibility testing?
 
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)?
  
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. (Choose one or more)





















































11. * Please note your membership in any of the following national societies or special interest groups. (Choose one or more)










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 GeneticsDirectory@cancer.gov.