ONCOLOGY NURSING SOCIETY
RADIATION THERAPY TRAINER COURSE
q November 10, 2005 Phoenix, AZ - Application Deadline – September 12, 2005
APPLICATION FORM
PLEASE TYPE ALL INFORMATION
Contact Information:
Name: Credentials: Certification:
Address:
City: State: Zip+4:
Home Telephone: Work Telephone:
FAX: E-mail address (required):
ONS Member # RN License # :
Employer
Radiation Therapy SIG Member: Yes No
Experience:
Which of the following best describes your employment position? (check only one)
Staff nurse
Advanced practice nurse
Educator
Administrator/Manager
Other (please describe):
Radiation Therapy Experience:
How many years have you worked in radiation oncology nursing? years
(Minimum of 3 years required)
Indicate the types of radiation therapy with which you have had experience. Check all that apply.
External Beam Intraoperative IORT
Prostate Brachytherapy Radioactive Iodine SRS / SRT
HDR TBI
LDR Intravascular brachytherapy
Partial Breast Irradiation Administration of radioprotectants
Education:
Bachelor’s degree in nursing
Bachelor’s degree in another health related field (Please specify your specialty)
Master's degree (specialty)
Doctorate (specialty)
Please use the space provided below only to answer the following questions.
COURSE INFORMATION:
1. State your main reason for wanting to attend the ONS Radiation Therapy Trainer Course.
2. Describe your professional education teaching experience (e.g., teaching in-services, program development, workshops, etc.).
3. Briefly describe how your clinical interests relate to the care of patients receiving radiation therapy?
4. A letter of recommendation is required. The attached Recommendation Form may be used.
5. You may attach or email a resume or curriculum vitae (CV) with this application.
COURSE FEE
The ONS Radiation Therapy Trainer Course Fee is $575. This fee includes course registration and course materials including the required textbook and teaching materials that you will use to present the course to others. A CD-ROM that includes all slides and speaker notes for the full one-day course is included.
Please DO NOT send the fee with your application. You will be invoiced if your application has been accepted.
APPLICATION SUBMISSION:
E-mail application, letter of recommendation, and resume or CV to:
OR MAIL the application, letter of recommendation, and resume or CV to:
ONCOLOGY NURSING SOCIETY
Education Cancer Care Issues Team
ATTN: Kristina Gantner
125 Enterprise Drive
Pittsburgh, PA 15275-1214
APPLICATION DEADLINE:
q November 10, 2005 Phoenix, AZ - Application Deadline – September 12, 2005
ONS Radiation Therapy Trainer Course
Recommendation Form
This form may be used to submit a recommendation for an individual interest in becoming an ONS Radiation Therapy Course Trainer. This form must be typed or neatly printed.
Part I – Trainer Applicant
Name of Applicant:
Part II – Information about the individual providing the recommendation
Name: Credentials:
Title:
Employer:
Address:
City: State: Zip:
E-mail address:
Relationship to Trainer Applicant:
Part III – Recommendation
In 250 words or less, describe the applicant’s accomplishments in nursing education and their involvement in the care of patients receiving radiation therapy. This nursing education can be in the form of unit-based in-services, institution based conferences, or other large conferences. Please speak directly to your personal experience of the applicant’s educational abilities.
Signature: Date: