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OMB No. 0925-xxxx Expiry Date xx-xx-20xx
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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-xxxx). Do not return the completed form to this address.
Introduction
You are listed as a provider of genetics services in the NCI Cancer Genetics Services Directory as part of
the National Cancer Institute's Web site. Below is an electronic form that shows the information about you
and your services currently listed in the Directory. Please review the information and update it by typing
any changes directly into the boxes.
If you have any questions, please send an email to GeneticsDirectory@cancer.gov.
1. Contact Information
Please verify all contact information. This address is used to contact you for data verification purposes. It
may be the same as one of the practice locations listed in the online directory (see Practice Locations
immediately below).
Last Name: Baggins
First Name: Frodo
Middle Initial(s): S.
Suffix:
Institution: Cancer Center of Middle-Earth
Contact Address: Middle-Earth Cancer Center
1511 Gandalf Gate Rd
Mordor, ME 13579
Telephone: 123-456-7890
Fax: 123-456-7899
* E-mail: John.Doe@middle.earth
Publish email address in Yes
directory?
Web Address: www.middle.earth/ring/
2. Practice Locations
Please verify the practice location(s) for consultations and patient referrals, and list additional locations
(up to a maximum of four total locations).
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Location 1
Institution: Cancer Center of Middle-Earth
Contact Address: Cancer Center of Middle-Earth
1511 Gandalf Gate Rd
Mordor, ME 13579
* Telephone: 123-456-7890
Location 2
Institution:
Contact Address:
* Telephone:
3. Type of Health Care Professional
Please verify information on type of health care professional (check all that apply).
Clinical Psychologist (Ph.D., Psy.D.)
Clinical Social Worker (M.S.W., D.S.W.)
Genetic Counselor (M.S., M.Sc., M.A., C.G.C.)
Geneticist (Ph.D.)
Nurse (R.N., B.S.N., M.S.N., M.S., M.A., Ph.D.)
Physician (M.D., D.O., or foreign equivalent)
Other
4. Degree(s)
Please verify academic degrees.
5. Specialties and Certifications
Please verify genetics and oncology specialties and board certifications.
Specialty
Board Certified Board Eligible Year Eligible
Clinical Biochemical Genetics
Clinical Cytogenetics
Clinical Genetics
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Clinical Molecular Genetics
Genetic Counseling
Gynecologic Oncology
Hematology
Medical Genetics
Medical Oncology
Molecular Genetic Pathology
Oncology Nursing
Pediatric Hematology-Oncology
Radiation Oncology
6. Team Services
Are you a member of an interdisciplinary team?
Yes
No
If so, please verify the services provided by you or members of your team (check all that apply).
Appropriate pre- and post-test counseling and informed consent
Follow-up plan of care
Genetic susceptibility testing
Patient cancer risk assessment
Patient genetics education
7. Professional Services
Do you currently provide professional services?
Yes
No
Are you willing to accept calls or e-mails from individuals seeking familial cancer risk counseling and/or
genetic susceptibility testing?
Yes
No
Please indicate if there are restrictions to services provided (e.g., a person must be eligible for a clinical
trial in order to receive services).
Yes (Please specify)
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No
8. Predisposing Syndromes
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.
Adenomatous polyposis, familial
Multiple endocrine neoplasia 2
Ataxia-telangiectasia
Neurofibromatosis 1
Basal cell nevus syndrome
Neurofibromatosis 2
Bloom syndrome
Osteochondromatosis
Breast/other (BRCA2)
Pancreatic cancer, familial
Breast/ovarian (BRCA1)
Paraganglioma, familial
Carcinoid syndrome, familial
Peutz-Jeghers syndrome
Carney syndrome
Prostate cancer, familial
Chordoma, familial
Renal cancer, familial
Colon (HNPCC)
Retinoblastoma, hereditary
Cowden syndrome
Rothmund-Thomson syndrome
Esophagus, with tylosis
Testicular carcinoma, familial
Fanconi anemia
Tuberous sclerosis complex
Gastric cancer, familial
Von Hippel-Lindau syndrome
Hodgkin lymphoma, hereditary
Werner syndrome
Li-Fraumeni syndrome
Wilms tumor, hereditary
Melanoma, hereditary
Xeroderma pigmentosum
Multiple endocrine neoplasia 1
9. Memberships
Please indicate your membership in any of the following national societies or special interest groups.
American College of Medical Genetics (ACMG)
American Psychological Association (APA)
American Society of Clinical Oncology (ASCO)
American Society of Human Genetics (ASHG)
Collaborative Group of the Americas on Inherited Colorectal Cancer (CGA-ICC)
International Society for Gastrointestinal Hereditary Tumors (InSiGHT)
International Society of Nurses in Genetics (ISONG)
NSGC Special Interest Group in Cancer
National Society of Genetic Counselors (NSGC)
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ONS Cancer Genetics Special Interest Group
Oncology Nursing Society (ONS)
10. Completion
When you have reviewed the information above and made any necessary changes, please select the
appropriate button to submit your reply.
Update My Record
No Changes
file://C:\Temp\BurdenMailer.html
Please update my profile with the changes I have made.
No changes are required.
3/4/2011
| File Type | application/pdf |
| File Title | file://C:\Temp\BurdenMailer.html |
| Author | volker |
| File Modified | 2011-03-04 |
| File Created | 2011-03-04 |