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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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