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Cancer Consortium Survivorship Roster

Survivorship focuses on the health and well-being of a person with cancer from the time of diagnosis until the end of life. This includes the physical, mental, emotional, and social effects of cancer that begin at diagnosis and continue through treatment and beyond. We want to develop and maintain an active roster of interested Consortium members so that we can build a stronger community of researchers and clinicians interested in this domain of research and clinical care across Consortium institutions. To accomplish this, please complete the short survey below.

Last Name

* must provide value

First name

* must provide value

Degree/ Credential

* must provide value

Master degree (e.g. MA, MPH, MS, MHA, MBA)

MD / DO

NP (Nurse Practitioner)

PA-C

PhD / DrPH / ScD

Other

3a.

If other degree/credential, please specify

Primary institution(s)

* must provide value

Fred Hutchinson Cancer Center

Seattle Children's

University of Washington

Department(s) / Division(s)

Academic title (e.g. clinical instructor, or assistant, associate, full professor)

Any other institutional titles?

Are you engaged in any research projects involving cancer survivors?

* must provide value

Yes No

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8a.

Please give a short description of research interests

Expand

Are you engaged in the clinical care of cancer survivors?

* must provide value

Yes No

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9a.

Please give a short description of survivor care provided

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(One selection allowed per column)

	Access to survivorship clinic patients for research (adult or pediatric)
	CME events focused on survivorship
	Helping develop survivorship clinical services
	Microgrants (< $5,000)
	Pilot funding (up to $50,000)
	Research seminars or symposia (not CME) on survivorship topics

11.

Contact email

* must provide value

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