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Organization Application for Membership on the CoC
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1.
Organization Information
(Required.)
Name of Organization
Date Founded
Address
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
Website
Phone Number
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2.
Main Contact Information
(Required.)
Full Name
Title
Email Address
Phone Number
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3.
Executive Director
(Required.)
Full Name
Email Address
Phone Number
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4.
If you are a professional, non-profit organization please indicate if your organization meets the following criteria:
Is national in scope
Has a national membership
Has a board of directors or appropriate governance structure
Has organizational bylaws
Holds an annual or bi-annual national meeting
Has effectively addressed equity in cancer care
(Required.)
Yes
No
Other (please specify)
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5.
Organization Mission Statement
(Required.)
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6.
Total Membership (#)
(Required.)
7.
Please describe any credentialing or accreditation activities (if applicable).
8.
Names and titles of current officers:
9.
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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10.
Please describe how CoC membership will benefit your organization.
(Required.)
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11.
Please describe how your organization actively addresses equity in cancer care.
(Required.)
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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).
(Required.)
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.
(Required.)
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
14.
Please attach your letter of interest in .PDF or .DOC, .DOCX format.
Choose File
No file chosen
15.
Information of individual completing this application (if different from main contact person).
Full Name
Position within the organization
Email Address
Phone Number
16.
Any additional supporting materials may be attached in this section.
Choose File
No file chosen
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.
