Winship Membership Application

Personal Information

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

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

Office Location
Required Documents

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

Program Selection
Funded Research & Training Grants

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

Yes No

If yes, are any peer-reviewed?

Yes No

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

Yes No

If yes, are any peer-reviewed?

Yes No
Clinical Trials Involvement

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

Yes No

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

Cancer-Related Publications

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

Yes No

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?

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

Signature

The NCI guidelines require that new membership in the 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 (winmemb@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.