Form 1 Genetic Web-based Application

10/13/2017

NCI Cancer Genetics Services Directory

NCI Cancer Genetics Services Directory
OMB No. 0925-0639 Expiry Date 10/31/2017
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
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information unless it displays a currently valid OMB control number. Send comments regarding this
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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.

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:
First Name:
Middle Initial(s):
Suffix:
Institution:
Contact Address:

Telephone:
Fax:
* E-mail:
Publish email address in Yes
directory?
Web Address:

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).

Location 1
Institution:
Contact Address:

* Telephone:
Location 2
Institution:
Contact Address:

* Telephone:
Location 3

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Institution:
Contact Address:

* Telephone:
Location 4
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
Clinical Molecular Genetics
Genetic Counseling
Gynecologic Oncology
Hematology
Medical Biochemical Genetics
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?

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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)

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.
Ataxia-telangiectasia

Multiple endocrine neoplasia
type 2

Basal cell nevus syndrome

Multiple myeloma, familial

Beckwith-Wiedemann syndrome

Neuroblastoma, hereditary

Birt-Hogg-Dubé syndrome

Neurofibromatosis type 1

Bloom syndrome

Neurofibromatosis type 2

Breast/ovarian cancer, hereditary (BRCA1)

Nijmegen breakage syndrome

Breast/ovarian cancer, hereditary (BRCA2)

Pancreatic cancer, hereditary

Carney complex, types I and II

Paraganglioma, hereditary

Chordoma, familial

Peutz-Jeghers syndrome

Colon cancer, hereditary non-polyposis Lynch syndrome

Polyposis, familial adenomatous

Costello syndrome

Polyposis, familial juvenile

Cowden syndrome

Polyposis, MYH-associated

Dyskeratosis congenita

Prostate cancer, hereditary

Esophageal cancer with tylosis

Renal cell cancer, hereditary

Exostoses, hereditary multiple

Retinoblastoma, hereditary

Fanconi anemia
Gastric cancer, hereditary diffuse

Rhabdoid predisposition
syndrome
Rothmund-Thomson syndrome

Gastrointestinal stromal tumor, hereditary

Simpson-Golabi-Behmel
syndrome

Lymphoma, Hodgkin, familial

Testicular germ cell tumor,
familial

Hyperparathyroidism, familial

Thyroid cancer, familial
medullary

Leukemia, acute myeloid, familial

Thyroid cancer, familial nonmedullary

Leukemia, chronic lymphocytic, familial

Tuberous sclerosis complex

Li-Fraumeni syndrome

Von Hippel-Lindau syndrome

Lymphoma, non-Hodgkin, familial

Waldenström
macroglobulinemia, familial

Melanoma, hereditary, multiple

Werner syndrome

Mosaic variegated aneuploidy

Wilms tumor, familial

Multiple endocrine neoplasia type 1

Xeroderma pigmentosum

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)
ONS Cancer Genetics Special Interest Group

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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

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Please update my profile with the changes I have made.
No changes are required.

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