The application has four steps. Please read carefully and gather all the appropriate information before you begin. You must complete the application in one session. Incomplete applications will not be considered.
Step 1. Institution/Program Information
- • Institution contact information
- • Type of institution (e.g., nonprofit, for profit, HMO, government)
- • Type of cancer center (e.g., NCI designated, community/general hospital,
ambulatory/physician’s office, academic teaching, VA)
- • Percentage of cancer patients treated at institution
- • Number of patients treated annually
- • Percentage of cancer patient population by ethnicity and race
- • If you have a psychosocial oncology program, how many patients are screened for distress annually?
Steps 2 and 3. Applicant Information
The following information is necessary for both applicants:
- • Name, job title, contact information
- • Discipline
- • Do you prescribe?
- • Do you bill?
- • CV or biosketch
The information listed below should be included. Not all applicants will have
experience in all areas. You do not need to reformat your existing curriculum vitae.
Add a separate page if needed to address specific areas.
- - Professional education
- - Professional experience
- - Position held at institution
- - Hospital or facility committees
- - Presentations
- - Publications
- - Membership in professional organizations
- - Specialty certifications
- • Statement of interest in the course (limit 1,900 characters/300 words)
- • The following questions are optional: Gender, ethnicity and race
Step 4. Institutional Goals and Expectations
- • Three distress screening focused goals to be accomplished following the course.
- • Examples of goal themes include the following:
- - Identify psychosocial cancer care resources within the institution and the
- - Adapt current psychosocial health services to highlight a psychosocial oncology
- - Establish a psychosocial health services program for one clinic
- • A letter of commitment and support (preferably two) from an administrator(s)
To be eligible for this program, you and your colleague must have:
- • An interest in improving psychosocial
oncology care within your practice setting
- • 2 letters of support from administrators
If accepted into this program, you and your colleague will be expected to:
- • Commit to improving psychosocial oncology
- care in your practice setting
- • Attend two consecutive annual one-day
• Participate in the development of pre-course
institutional goals, post-course evaluation,
and post-course goal updates at 6-, 12- and