CSSP Committee Member Application Form 2025 Survey

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2. ACS member ID number (if applicable/known)

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3. Institution/Organization (Required.)

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4. Email (Required.)

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5. Business phone (Required.)

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6. Specialty (Required.)

Acute Care Surgery

Burn Surgery

Cardiac Surgery

Cardiothoracic Surgery

Colo-Rectal Surgery

Complex Pediatric Otolaryngology

General Surgery

GYN Oncology

Hand Surgery

Hospice & Palliative Surgery

Minimally invasive Surgery

Neurosurgery

Neurosurgery – no cranial practice

Neurotology

OB/GYN

OMFS

Ophthalmic Surgery

Ortho Hand

Ortho Joints

Ortho Sports Medicine

Ortho Trauma

Orthopedic Spine

Orthopedic Surgery

OTO

Pediatric Surgery

Pediatric Trauma Surgery

Plastic Cosmetic

Plastic Craniomaxillofacial

Plastic Hand

Plastic Surgery

Reconstructive urology

Rural Surgery

Sleep Medicine

Surgical Critical Care

Surgical Oncology – Breast

Surgical Oncology -Complex Abdominal

Thoracic Surgery / Oncology

Transplant Surgery

Trauma Surgery

Urology

Vascular Surgery

Vein Surgery

Other (please specify)

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7. What other ACS Committees are you applying to? (You may apply up to 2)

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8. Please list other ACS committee(s) you currently serve on.

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9. Please attach a copy of your CV or biographical sketch. (PDF file)
*Please note, you are not required to share any sensitive information on your file.

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10. Number of years as a practicing cancer professional after completion of training (enter 0 if you are still in training). (Required.)

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11. Cancer discipline (Required.)

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12. Areas of expertise and/or practice. (Check all that apply) (Required.)

Breast malignancies

Colorectal malignancies

Endocrine malignancies

Gastroesophageal malignancies

Gynecologic malignancies (cervix, uterine, vulvar, etc.)

Head and neck malignancies

Hematologic malignancies

Liver and pancreas malignancies

Melanoma and skin malignancies

Neurologic malignancies

Non-colorectal gastrointestinal malignancies

Peritoneal surface malignancies

Sarcoma

Small bowel malignancies

Soft tissue malignancies

Thoracic malignancies

Urologic malignancies (prostate, kidney, testicular)

Other (please specify)

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13. Are you a member of any other cancer programs or cancer-related professional organizations? (Check all that apply) (Required.)

American Association for Cancer Research

American Cancer Society

American College of Radiology

American College of Surgeons

American Society for Radiation Oncology

American Society of Breast Surgeons

American Society of Clinical Oncology

American Society of Colon and Rectal Surgeons

Americas Hepato-Pancreato-Biliary Association

College of American Pathologists

Connective Tissue Oncology Society

National Comprehensive Cancer Network

Society for Surgery of the Alimentary Tract

Society of American Gastrointestinal and Endoscopic Surgeons

Society of Gynecologic Oncology

Society of Surgical Oncology

Society of Thoracic Surgeons

Other (please specify)

Committee Interest

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14. Please select your committee of interest. (Select only one) (Required.)

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15. Please indicate which accreditation program your local institution participates in currently. (Check all that apply)

CoC

NAPBC

NAPRC

None of the above

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16. Have you been a site reviewer? (Check all that apply) (Required.)

CoC

NAPBC

NAPRC

Have not been a site reviewer

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17. Have you been a local program leader of your accredited program? (Check all that apply)

CoC Cancer Liaison Physician

CoC Quality Officer

CoC Cancer Committee Chair

CoC State Chair

NAPBC Breast Program Director

NAPRC Rectal Cancer Program Director

Other (please specify)

Statement of Intent

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18. Describe relevant cancer activities that make you eligible and qualified to participate in this committee. (250 words) (Required.)

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19. What contributions would you expect to make towards ensuring that the concerns of all committee members and patients are addressed in the committee's decision-making and activities? (150 words) (Required.)

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20. Describe other relevant activities that make you eligible and qualified to participate in this committee (i.e., work in the field of informatics, analytics, leadership, etc.). (150 words) (Required.)

CSSP Committee Member Application Form 2025

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* 1. Name and credentials (Required.)

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* 2. ACS member ID number (if applicable/known)

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* 3. Institution/Organization (Required.)

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* 4. Email (Required.)

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* 5. Business phone (Required.)

Question Title

* 6. Specialty (Required.)

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* 7. What other ACS Committees are you applying to? (You may apply up to 2)

Question Title

* 8. Please list other ACS committee(s) you currently serve on.

Question Title

* 9. Please attach a copy of your CV or biographical sketch. (PDF file)*Please note, you are not required to share any sensitive information on your file.

Question Title

* 10. Number of years as a practicing cancer professional after completion of training (enter 0 if you are still in training). (Required.)

Question Title

* 11. Cancer discipline (Required.)

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* 12. Areas of expertise and/or practice. (Check all that apply) (Required.)

Question Title

* 13. Are you a member of any other cancer programs or cancer-related professional organizations? (Check all that apply) (Required.)

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* 14. Please select your committee of interest. (Select only one) (Required.)

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* 15. Please indicate which accreditation program your local institution participates in currently. (Check all that apply)

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* 16. Have you been a site reviewer? (Check all that apply) (Required.)

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* 17. Have you been a local program leader of your accredited program? (Check all that apply)

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* 18. Describe relevant cancer activities that make you eligible and qualified to participate in this committee. (250 words) (Required.)

Question Title

* 19. What contributions would you expect to make towards ensuring that the concerns of all committee members and patients are addressed in the committee's decision-making and activities? (150 words) (Required.)

Question Title

* 20. Describe other relevant activities that make you eligible and qualified to participate in this committee (i.e., work in the field of informatics, analytics, leadership, etc.). (150 words) (Required.)

1. Name and credentials (Required.)

2. ACS member ID number (if applicable/known)

3. Institution/Organization (Required.)

4. Email (Required.)

5. Business phone (Required.)

6. Specialty (Required.)

7. What other ACS Committees are you applying to? (You may apply up to 2)

8. Please list other ACS committee(s) you currently serve on.

9. Please attach a copy of your CV or biographical sketch. (PDF file)
*Please note, you are not required to share any sensitive information on your file.

10. Number of years as a practicing cancer professional after completion of training (enter 0 if you are still in training). (Required.)

11. Cancer discipline (Required.)

12. Areas of expertise and/or practice. (Check all that apply) (Required.)

13. Are you a member of any other cancer programs or cancer-related professional organizations? (Check all that apply) (Required.)

14. Please select your committee of interest. (Select only one) (Required.)

15. Please indicate which accreditation program your local institution participates in currently. (Check all that apply)

16. Have you been a site reviewer? (Check all that apply) (Required.)

17. Have you been a local program leader of your accredited program? (Check all that apply)

18. Describe relevant cancer activities that make you eligible and qualified to participate in this committee. (250 words) (Required.)

19. What contributions would you expect to make towards ensuring that the concerns of all committee members and patients are addressed in the committee's decision-making and activities? (150 words) (Required.)

20. Describe other relevant activities that make you eligible and qualified to participate in this committee (i.e., work in the field of informatics, analytics, leadership, etc.). (150 words) (Required.)