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Consultant Skills List Form
Home
Links
Contact
Contingency Planning
About Us
Newsletters
Online Forms
Project Request Form
Consultant Skills List Form
Consultant Skills List Form
All information contained in this form is confidential and will not be released to others.
Name:
Email:
Address:
Phone (work):
Phone (home):
Total years experience:
Hospital based registry experience:
Central registry experience:
Is certification current?
Is certification current?
Yes
No
Level of Education:
Cancer research experience:
Worked for ACOS approved hospital?
Worked for ACOS approved hospital?
Yes
No
Worked for a Non-ACOS hospital:
Worked for a Non-ACOS hospital:
Yes
No
Supervisory experience:
Training experience:
Member of NCRA:
Member of NCRA:
Yes
No
Member of state organization:
Have you been through a survey?
Have you been through a survey?
Yes
No
Have you independently contracted?
Have you independently contracted?
Yes
No
Have you worked for a contracting company?
Have you worked for a contracting company?
Yes
No
Are you willing to travel?
Are you willing to travel?
Yes
No
Are you setup to work from home?
Are you setup to work from home?
Yes
No
What Cancer Registry Software are you skilled in using?
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