ASCO Measure Representative Form

Thank you for your interest ASCO measure development. ASCO offers organizations the opportunity to provide expertise and support by nominating organizational representatives.

Measure Clinical Area*

Please provide the disease site or clinical area for which you are nominating representatives.

Organization*

Please provide the name of the organization for which you are requesting representation.

Staff Contact Name*

Staff Contact Email*

Form Date Field*

Nominated Representative (1) Name*

Nominated Representative (1) Hospital/Practice*

Please provide hospital/practice name and location.

Nominated Representative (1) Email*

Nominated Representative (2) Name

Nominated Representative (2) Hospital/Practice

Please provide hospital/practice name and location.

Nominated Representative (2) Email

Nominated Representative (3) Name

Nominated Representative (3) Hospital/Practice

Please provide hospital/practice name and location.

Nominated Representative (3) Email

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