ASCO Medical Education Community of Practice Registration

Welcome to the ASCO Medical Education Community of Practice (CoP)! Please complete the following questions so we can formally add you to our membership list and better understand your needs and interests.

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* 1. Name

First Name

Last Name

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* 2. Institution

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* 3. Preferred Email

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* 4. Are you an ASCO member?

Yes

Unsure

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* 5. Role (Check one)

Advanced Practice Provider

Hematologist/Oncologist

Hospitalist

Nurse

PharmD

Radiation Oncologist

Surgical Oncologist

Social Worker

Trainee

Other (please specify)

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* 6. Area of Practice (Check all that apply)

Hematology

Nursing

Oncology

Pharmacy

Radiation Oncology

Social Work

Surgical Oncology

Other (please specify)

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* 7. Area of Education Interest (Check all that apply)

Administration and Leadership

Assessment and Evaluation

Continuing Medical Education

Curriculum Development

Faculty Professional Development

Learning Theory/Learning Science

Medical Education Research/Scholarship

Mentorship

Teaching Fellows

Teaching Residents

Teaching Medical Students

Other (please specify)

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* 8. Please contact me with potential leadership opportunities within ASCO Medical Education CoP.

Yes

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* 9. Please contact me with potential volunteer opportunities within ASCO Education.

Yes

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* 10. What do you hope to gain from your participation in the CoP?

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* 11. What Medical Education challenges can the CoP help you overcome?

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* 12. What is your gender identity? (Optional)

Female

Male

Non-binary

Prefer not to answer

Other (please specify)

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* 13. What is your race? (Optional, check all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer

Other (please specify)

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* 14. What is your ethnicity? (Optional)

Hispanic or Latino or Spanish Origin

Not Hispanic or Latino or Spanish Origin

Prefer not to answer

ASCO Medical Education Community of Practice Registration

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* 1. Name

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* 2. Institution

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* 3. Preferred Email

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* 4. Are you an ASCO member?

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* 5. Role (Check one)

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* 6. Area of Practice (Check all that apply)

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* 7. Area of Education Interest (Check all that apply)

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* 8. Please contact me with potential leadership opportunities within ASCO Medical Education CoP.

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* 9. Please contact me with potential volunteer opportunities within ASCO Education.

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* 10. What do you hope to gain from your participation in the CoP?

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* 11. What Medical Education challenges can the CoP help you overcome?

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* 12. What is your gender identity? (Optional)

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* 13. What is your race? (Optional, check all that apply)

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* 14. What is your ethnicity? (Optional)

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* 15. Do you have any additional questions?