Membership Application

Please read the MCW Cancer Center Membership Guidelines before completing this application.

Items marked with * are required.

Contact Information

First Name*  Middle Initial  Last Name*

Degree*          Academic Title* 

Primary Department*   Division

Social Security Number (last 4 digits)*        Date of Birth*

Employee ID Number* 

Email Address*

Office Location (If not on campus, list full mailing address)

*

Phone Number*                         FAX Number*

Assistant's Name        Assistant's Phone Number

Membership Type

Indicate the category of membership*:   Research Member     Clinical Member     Affiliate Member
 

Choose a primary Research Program from the list: Choose a Research ProgramCancer Susceptibility & ChemopreventionCancer Cell Signaling & MetabolismAngiogenesis, Metastasis & the Tumor MicroenvironmentCancer ImagingHematologic Malignancy & TransplantationPopulation SciencesExperimental Therapeutics

For Research Membership applicants, please provide a brief statement below regarding your
primary cancer-related research interests and activities (limited to 1700 characters):
 

If you are applying for a Clinical Membership, check the focus groups in which you would like to participate:

Breast Oncology                         
Developmental Therapeutics       
Endocrine Oncology                  
Gastrointestinal Oncology           
Genitourinary Oncology                
Gynecologic Oncology                   
Head and Neck Oncology
Leukemia/Lymphoma/Transplant
Melanoma
Musculoskeletal Oncology
Neuro-Oncology     
Pediatric Oncology                                                   
Thoracic Oncology
 

For Clinical or Affiliate Membership applicants, please describe your
cancer-related interests (clinical education, outreach, etc./limited to 1700 characters)
 

Funded Research/Training Grants

Are you the Principal Investigator on any cancer-related funded research projects?* 
 Yes       No           
IF YES - Is any funding peer-reviewed?**  Yes      No 

Are you the co-investigator or collaborator on any cancer-related funded research projects?* 
 Yes       No
IF YES - Is any funding peer-reviewed?**  Yes      No

**See Membership Guidelines for qualifying funding organizations.

Shared Resources

Check the box for the shared resources (core facilities) that you would potentially use:*

Biostatistics

Clinical Trials Office

Flow Cytometry           

Tissue Bank

 Small Animal Imaging

Clinical & Translational Research Lab

Observational Methods

Bioenergetics

Lymphocyte Propagation          

None
 

Clinical Trials Involvement

Have you enrolled patients onto cancer clinical trials in the past year?*  Yes     No

IF YES- indicate in the fields below, how many of those patients have been registered under your name on cancer-related clinical trials over the past year?

Institutional                  Cooperative Group                   Industry     

If you have not registered patients, but have been instrumental in identifying or treating patients on clinical trials, please indicate specific trials and physicians that you have collaborated with (limited to 200 characters):

If you are the Principal Investigator of a currently open cancer clinical trial, please list the Clinical Trial Sponsor, Title and the Human Subjects approval number below. Please specifically note any institutional, investigator-initiated trial. Please email additional pages to Andrea Brown if necessary (see email submission checklist below).
 

Cancer-related Publications

Do you have any peer-reviewed cancer-related publications (2008-present)?* Yes        No
If yes, indicate on your CV or on another page, which publications (2008 to present only) are cancer-related.
 

Email Submission Checklist

Be certain to email the following documents to Sheri Sasaki:

►  NIH Biosketch (06/09)

►  Curriculum Vitae (indicate which publications are cancer-related, 2008-present only)

►  Project/grant information using the NIH Other Support format along with the project/grant abstract and indicate which projects are cancer-related. Make sure pending projects are included as well.

►  Grant abstracts for all cancer-related grants

►  Additional clinical trial information as needed

►  Photo suitable for website display

Signature Confirmation

The NCI guidelines require that new membership in the MCW Cancer Center is reviewed at the time of application and again annually thereafter. While we annually request some information from you directly (such as biosketches, web updates, etc), we also have the ability to obtain some data from our central College data sources such as the Oracle system and the eBridge system. From these systems we obtain information regarding your cancer-related grant activity and effort reports for cancer-related grants and clinical trials. Obtaining this information centrally reduces the amount of information we need to obtain from you personally. Acceptance of membership indicates your willingness to allow us to access this information on your behalf. Please contact Andrea Brown (andreabrown@mcw.edu or 414-955-2801) if you have any questions.

I have reviewed the MCW Cancer Center Membership Guidelines and agree to follow these guidelines as well as actively participate in the further development of the MCW Cancer Center. My full name and date entered below in the box serves as an electronic signature.

Signature:*   Date:*