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Winship Membership Application

Personal Information

Name

Degrees

Title

Employee ID

Your 7 digit employee number

Email

Personal URL

Gender

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Ethnicity

Primary Department

School

Area of Clinical Interests or Research Interests

Please provide a brief description of your research interests. Please highlight the cancer relevance of your research, if it is not obvious.

Collaborations

Please list all active and recent collaborations with other Emory University cancer researchers and clinicians.

Office Location

Address

City

State

Zip Code

Phone

Fax (optional)

Program Selection

Primary program

Secondary program

Funded Research & Training Grants

Are you the Principal Investigator (PI) in any cancer-related funded research projects?

If yes, are any peer-reviewed?

Are you a co-investigator or collaborator on any cancer-related funded research projects?

If yes, are any peer-reviewed?

Clinical Trials Involvement

Have you enrolled patients onto cancer clinical trials in the past year?

If yes, how many of those patients have been registered under your name on cancer-related clinical trials over the past year?

Institutional

Cooperative Group

Industry

Cancer-Related Publications

Do you have any peer-reviewed cancer-related publications (2001-present)?

If yes, indicate on your CV or on another page, which publications (2001 to present only) are cancer-related.

Winship Shared Resources

Which Winship Cancer Institute Shared Resource would you potentially use?

Bioinformatics and Systems Biology

Biostatistics Shared Resource

Cancer Animal Models

Cancer Tissue and Pathology

Emory Integrated Genomics

Emory Integrated Proteomics

Integrated Cellular Imaging

Intervention Development, Dissemination and Implementation

Winship DATA

Pediatrics/Winship Flow Cytometry

Winship Immune Monitoring

Please describe any shared resources that are not currently part of the Winship Cancer Institute that you feel would benefit your research.

Mentorship

Do you currently have a mentor?

Mentor Name

Do you currently have a mentee?

Mentee Name

Would you like assistance finding a mentor?

Would you like assistance finding a mentee?

Required Documents

Please upload the most current copy of your four-page NIH biosketch and most recent CV and other support pages

NIH Biosketch

Curriculum Vitae (CV)

Signature

The NCI guidelines require that new membership in Winship Cancer Institute 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 University data sources. From these systems we obtain information regarding your cancer-related grant activity and effort reports for cancer-related grants and clinical trials. This information does not include salary data. Obtaining this information centrally reduces the amount of information we need to obtain from you personally. Acceptance of membership in Winship indicates your willingness to allow us to access this information on your behalf. Please contact Susannah Conroy ( sconroy@emory.edu, 404-778-2218 ) if you have any questions.

I have reviewed the Winship Cancer Institute Membership Guidelines and agree to follow these guidelines as well as actively participate in the further development of the Winship Cancer Institute.

Signature

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