Specialty ( or research interests ) by which we can refer patients to you

B.	Other members of your organizations who you would like to be listed in this roster (e.g., physicians, certified genetics counselors, nurses, health educators)

	Name	Department / Institution	Specialty or Research Interests
1
2
3
4

C.	Do you provide genetic counseling or testing to any cancer patient population at this time:

No

Yes

Developing a clinical cancer genetics program

	If yes, please list specific diseases for which this service is offered:
	Breast Cancer
	Ovarian Cancer
	Colorectal Cancer
	Melanoma
	Other, please list

D.	Computer Support and Experience ( please check all that apply )

Have on-site access to the Internet Have computer capabilities for accessing CD-ROMS Have computer with audio capabilities Have had experience with continuing education on the Internet Have had experience working with Adobe Acrobat Have database experience

E.	I prefer MACGN communication:

By Mail

By E-Mail

By Fax

F.	My most immediate priority need in the area of PROFESSIONAL EDUCATION in cancer genetics is:

G.	My most immediate priority need in the area of PATIENT EDUCATION in cancer genetics is:

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