Name

Title (Role - i.e. Patient Educator, Director etc.)

Organization

Email Address

Phone Number

Please list the top 5 cancer types that you treat in your patient population (i.e. breast, lung, colon, etc.)

Custom Information: Custom Information: Our organization has custom information that we want to be added to our CancerHelp Online website

Types of Custom Handouts: (please check all that apply) Types of Custom Handouts: (please check all that apply) Patient Education Handouts/Teaching Documents Brochures and/or publications not from the National Cancer Institute (NCI) Support Groups Classes Survivorship days or programs Newsletters Patient Care and Support Programs Clinical Trials information Other

If you checked "Other", please describe:

Number of Custom Handouts representing check marks above (approximately)

Any other information for us to know about

What type of staff training for CancerHelp Online do you prefer? What type of staff training for CancerHelp Online do you prefer? On-Site Training Webinar Training via conference call (less expensive)