Organization Application for Membership on the CoC

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* 1. Organization Information

Name of Organization

Date Founded

Address

City/Town

State/Province

ZIP/Postal Code

Website

Phone Number

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* 2. Main Contact Information

Full Name

Title

Email Address

Phone Number

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* 3. Executive Director

Full Name

Email Address

Phone Number

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* 4. Organization Mission Statement

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* 5. Total Membership (#)

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* 6. Please describe any credentialing or accreditation activities (if applicable).

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* 7. Names and titles of current officers:

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* 8. Please describe why your organization is seeking membership on the CoC, including specific examples of how your organization can add value to the CoC:

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* 9. Please describe how CoC membership will benefit your organization.

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* 10. Please confirm that your organization is national in scope and serves a national membership.

Yes

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* 11. Please describe how your organization actively addresses equity, diversity, and inclusion in cancer care.

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* 12. Please indicate the organization’s primary areas of involvement in the field of oncology and on Question 13 describe how your organization supports these related Commission on Cancer standards (check all that apply).

Prevention and Screening: 8.1 Addressing Barriers to Care

Prevention and Screening: 8.2 Cancer Prevention

Prevention and Screening: 8.3 Cancer Screening

Evaluation and Decision-Making: 2.5 Multidisciplinary Conferences

Evaluation and Decision-Making: 3.2 Evaluation and Treatment Services

Evaluation and Decision-Making: 4.4 Genetic Risk Assessment

Evaluation and Decision-Making: 4.5 Palliative Care Services

Evaluation and Decision-Making: 4.6 Rehabilitation Care Services

Evaluation and Decision-Making: 4.7 Oncology Nutrition Services

Treatment: 5.1 CAP Synoptic Reporting

Treatment: 5.2 Psychosocial Distress Screening

Treatment: 5.3 Breast Sentinel Node Biopsy

Treatment: 5.4 Breast Axillary Dissection

Treatment: 5.5 Primary Cutaneous Melanoma

Treatment: 5.6 Colon Resection

Treatment: 5.7 Total Mesorectal Excision

Treatment: 5.8 Pulmonary Resection

Surveillance: 4.3 Registrar

Surveillance: 4.8 Survivorship

Surveillance: 6.1 Registry Quality Control

Surveillance: 6.2 Data Submission

Surveillance: 6.3 Data Accuracy

Surveillance: 6.4 RCRS

Surveillance: 6.5 Patient Follow-up

Administrative; Organization; Facility; Credentials- 1.1 Administrative Commitment

Administrative; Organization; Facility; Credentials- 2.1 Cancer Committee

Administrative; Organization; Facility; Credentials- 2.3 Cancer Committee Meetings

Administrative; Organization; Facility; Credentials- 2.4 Cancer Committee Attendance

Administrative; Organization; Facility; Credentials- 3.1 Facility Accreditation

Administrative; Organization; Facility; Credentials- 4.1 Physician Credentials

Administrative; Organization; Facility; Credentials- 4.2 Oncology Nursing Credentials

Quality Improvement and Accountability: 2.2 Cancer Liaison Physician

Quality Improvement and Accountability: 7.1 Accountability and Quality Improvement Measures

Quality Improvement and Accountability: 7.3 Quality Improvement Initiative

Quality Improvement and Accountability: 7.4 Cancer Program Goal

Evidence and Research: 7.2 Monitoring Concordance with Evidence-Based Guidelines

Evidence and Research: 9.1 Clinical Research Accrual

Evidence and Research: 9.2 Commission on Cancer Special Studies

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* 13. Please describe how your organization supports these related Commission on Cancer standards.

If selected for membership, please evaluate your organization and its appointed representative’s ability to meet the following core expectations.

Serve a minimum, three-year term
Serve on, and actively participate in, a CoC standing committee
Attend, and actively participate in, at least one in-person meeting a year, which include the appointed committee and member organization representatives meeting
Financially support your representative’s travel and lodging to the in-person meetings
Report on CoC activities annually to your organization’s leadership and constituents
Contribute content about your organization’s activities to the Cancer Programs News newsletter

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* 14. Please attach your letter of interest in .PDF or .DOC, .DOCX format.

PDF, DOC, DOCX file types only.

Choose File

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* 15. Information of individual completing this application (if different from main contact person).

Full Name

Position within the organization

Email Address

Phone Number

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* 16. Any additional supporting materials may be attached in this section.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 17. Please enter your eSignature below:

For questions, please contact Victoria Hernandez, Cancer Programs Administrator, at cpmembership@facs.org or via phone (312) 202-5209.