Association of Community Cancer Centers (ACCC) Engagement Opportunity Form

Getting to Know You

Looking for ways to get involved with ACCC? You've come to the right form.

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* 1. Name

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* 2. Department

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* 3. Program/Institute/Organization

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* 4. Job Title

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* 5. Email Address

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* 6. Phone Number

ACCC provides a robust offering of engagement options, diverse in activities, interests, time and travel. Help us to find opportunities that suit you by answering a few questions.

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* 7. Tell us about your area(s) of professional expertise.

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* 8. What do you enjoy doing in your spare time?

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* 9. What types of activities interest you? (select as many or as few as you want)

Document Review

Editing

Educational Program Planning

Mentoring

Peer Engagement

Public Speaking

Sharing Best Practices

Social Media Sharing/Posting

Writing

Other (please describe)

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* 10. What are your areas of interest in cancer care? (select as many as you want)

Continuing Education

Disparities

Financial Navigation

Grassroots (Local) Involvement

Innovation and Research

Patient Experience and Treatment

Policy (Legislative or Regulatory)

Technology

Workforce

Other (please describe)

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* 11. What keeps you up at night?

Time and Travel

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* 12. Which best matches your time availability?

Up to 1 hour/month

1 - 5 hours/month

5-10 hours/month

Other (please describe)

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* 13. Which best matches your travel availability?

No travel

Local (within 60 miles)

Out of town (over 60 miles)

Other (please describe)

Anything Else?

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* 1. Name

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* 2. Department

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* 3. Program/Institute/Organization

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* 4. Job Title

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* 5. Email Address

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* 6. Phone Number

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* 7. Tell us about your area(s) of professional expertise.

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* 8. What do you enjoy doing in your spare time?

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* 9. What types of activities interest you? (select as many or as few as you want)

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* 10. What are your areas of interest in cancer care? (select as many as you want)

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* 11. What keeps you up at night?

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* 12. Which best matches your time availability?

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* 13. Which best matches your travel availability?

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* 14. Comments (feel free to ask any questions or add anything additional here)