ONS Genetics Short Course for Cancer Nurses APPLICATION

PLEASE NOTE: Only completed applications received by the stated deadlines are reviewed. First consideration is given to applicants who are active ONS members. Applicants are required to be oncology nurses with an advanced Master’s and/or Doctoral nursing degree.

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September 14-16, 2007, Pittsburgh, PA– (DEADLINE – August 2, 2007 - Will Close earlier if seats are filled)

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Please TYPE or PRINT clearly all information:

Name:

(First)(M.I.)(Last)(Credentials)

Home Address:

City: State: Zip Code:

Employed by:

Work Address:

City: State: Zip Code:

Home Phone Number:()Best time to call:

Work Phone Number: () Ext Best time to call:

Fax Number: () E-Mail (*required):

Setting (Please check all that apply):

Inpatient Outpatient Hospice Home CareRadiationSchool of Nursing

Other (Please describe):

Position Title: Certifications:

Are you an active ONS member? Yes No ONS # (if applicable):

Number of Years in Nursing:

Number of Years in Oncology Nursing:

Highest Nursing degree completed:

Highest non-Nursing degree completed:

Ethnic Group: African American Asian Hispanic/Latino Native American

Caucasian Other: Do Not Care to Respond

Please state your main reasons for wanting to attend this course. Limit your response to the space provided.

STATEMENT OF AGREEMENT

If I am accepted to this course, I agree to the following:

1.Complete pre-work and post-test (six hours maximum) assigned in preparation for attending program. Deadline for pre-work completion is September 7, 2007. Bring the completed pre-work to the September 14-16, 2007 course.

2.Attend and actively participate in the entire course as follows:

  • September 14-16, 2007 – Friday, September 14, 2007,10am-6pm, ET; Saturday, Saturday 15, 2007, 8am-5pm, ET; and Sunday, September 16, 2007, 7am-3pm, ET. Do not scheduled airline flight out of Pittsburgh, PA, prior to 5pm, ET, Sunday, September 16, 2007.

3.Complete all written program evaluations, project updates, and final reports.

4.Complete the competency examination (minimum score of 75%) within four weeks of completing the Genetics Short Course for Cancer Nurses.

5.Disseminate the knowledge gained in the Genetics Short Course for Cancer Nurses by delivering a one 4-hour workshop on basic and cancer genetics to other nurses in your local area by March 6, 2008.

6.Actively share information from the program and serve as a role model and mentor to others.

7.Make airline reservations to arrive before 10am, ET, Friday, September 14, 2007 and to depart after 5pm, ET, Sunday, September 16, 2007 for the September 14-16, 2007 course.

ONS will reimburse a maximum of $600 for airfare and meals for the course. ONS will make hotel reservations for the attendees at the courses.

8.Meet the course requirements including being an oncology nurse who has completed an advanced Master’s and/or Doctoral nursing degree.

  1. Receive reimbursement after returning both the Genetics Short Course exam and the completed travel reimbursement form with original itemized receipts to the ONS National Office.

(Signature of applicant) (Date of application)

Please submitthe application and signed Statement of Agreement to:

Oncology Nursing Society

Education Team

ATTN: Annette M. Parry Bush

Genetics Short Course for Cancer Nurses

125 Enterprise Drive

Pittsburgh, PA 15275-1214

Applications must reach ONS by August 2, 2007, 5pm, ET, for the September 14-16, 2007 course (Will close earlier if seats are filled)

Your Application and the signed statement of agreement can be emailed to the ONS Education Team ()

Please Do Not Fax your application.

An emailconfirmation is sent within three business days after your application is received.
You will be notified of your acceptance four weeks before the scheduled course date.