CCON BETA TEST

Thank you for your interest in participating as a beta tester for the Certified Clinical Oncology Navigator (CCON™) certification examination.

Please complete all required fields. Submission of this application does not guarantee acceptance. NCBC will review your application and contact you with additional information.

Questions? Contact NCBC at 574-401-8113 or aerial@breastcare.org

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1. First Name (Required.)

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2. Last Name (Required.)

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3. Please enter all applicable professional credentials, certifications, or licenses—for example: MD, DO, RN, NP, PA, RT, or LSW. If none, enter “None.” (Required.)

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4. Professional Title

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5. Facility or Organization Name

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6. Facility Mailing Address

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7. Suite Number

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8. Facility City

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9. Facility State

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10. Facility ZIP Code

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11. Work Phone Number

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12. Cell Phone Number

Home Mailing Address

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15. Home City

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16. Home State

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17. Home ZIP Code

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18. Which contact information do you prefer that NCBC use? (Required.)

BETA TESTER NOTICE
As a beta tester, you understand that the examination is being administered as part of the certification program’s development process. Because beta-test results must undergo additional analysis, receiving your examination score may take longer than the standard one-to-two-week timeframe.

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19. I understand that I am participating as a beta tester and that receiving my examination score may take longer than the standard one-to-two-week timeframe.

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20. Please enter your initials to confirm your acknowledgment. (Required.)

CERTIFICATION PROGRAM ELIGIBILITY REQUIREMENTS Please review each eligibility requirement and enter your initials to confirm that you meet and understand the requirement.

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21. Licensure - Licensed healthcare professionals (i.e. Registered Nurses, Radiologic Technologists, Advanced Practice Professionals, Physician Assistants, Doctor of Osteopathy, or Physicians) Candidate must hold a current, active, unencumbered license in accordance with their professional role and scope of practice. (Required.)

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22. Experience - Complete a minimum of 1 year of Oncology navigation practice (defined as 1500 hours) prior to applying for certification testing. Experience must be within the past 2 years. (Required.)

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23. Education - Complete at least eight hours of relevant focused educational courses in cancer care, and/or oncology navigation. Up to but not more than four hours of tumor board participation can be included. (Required.)

Please email a copy of your current professional license, a letter on letterhead from your supervisor/HR confirming your 1500 hours, and your required CEUs to aerial@breastcare.org

Use the subject line: CCON Beta Tester License Documentation—[Your Full Name].

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24. Professional License Number

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25. State or Jurisdiction Issuing the License

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26. License Expiration Date

PROGRAM UNDERSTANDING AGREEMENT I have read and understand the NCBC Certification Exam Security and Testing Policies provided with this application. I understand that this is a certification examination and not an educational course. Registration materials will be sent by email to eligible applicants who are registered at least 10 days before the certification examination date.

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27. I have read, understand, and agree to the NCBC Certification Exam Security and Testing Policies and the statement above. (Required.)

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28. By entering my full legal name below, I confirm that the information provided in this application is accurate and that my typed name constitutes my electronic signature. (Required.)

SURVEY COMPLETION MESSAGE Thank you for submitting your CCON™ Beta Tester Application. NCBC will review your application and supporting documentation. If you meet the eligibility requirements and are selected to participate, you will receive additional registration and examination instructions by email. Questions may be directed to aerial@breastcare.org or 574-401-8113.

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