Massey Membership Application Form

Massey Membership Application Form

Name*

Middle Initial

Last Name*

Degree*

Email*

Office Phone

Office Address

Lab Address

P.O Box Number

Country of Birth*

Gender Identity*

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LGBTQIA+ Community Member*

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Race*

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Ethnicity*

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Disability*

Do you have a disability as described by the American Disabilities Act? (Link: https://www.ada.gov/law-and-regs/ada/)

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Pronouns*

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Economically or Educationally Disadvantaged BG*

To be considered from a disadvantaged background, you must meet two or more of the following criteria:

Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act (Link: https://nche.ed.gov/legislation/mckinney-vento/)

Were or currently are in the foster care system, as defined by the Administration for Children and Families (Link: https://www.acf.hhs.gov/cb/focus-areas/foster-care)

Were eligible for the Federal Free and Reduced Lunch Program for two or more years (Link: https://www.fns.usda.gov/cn/income-eligibility-guidelines)

Have/had no parents or legal guardians who completed a bachelor's degree (Link: https://nces.ed.gov/pubs2018/2018009.pdf)

Were or currently are eligible for Federal Pell grants (Link: https://www2.ed.gov/programs/fpg/eligibility.html)

Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child

Grew up in one of the following areas (Only one of the two possibilities listed can be used as a criterion for the disadvantaged background definition):

a) a U.S. rural area, as designated by the Health Resources and Services Administration (Link: https://data.hrsa.gov/tools/rural-health), or

b) https://www.qhpcertification.cms.gov/s/LowIncomeandHPSAZipCodeListingPY2020.xlsx?v=1 (qualifying zip codes are included in the file).

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Military Status *

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Faculty Appointment*

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VCU School/College*

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Department*

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Provide a brief description of your current cancer-related research (Max. 1000 characters)*

Disease-focus*

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Do You Have Any Active Funding?*

If yes, please describe in field below.

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Please provide grant information (if needed)

Provide grant number(s), funding agency, funding period, role on project

Describe your pending or unfunded cancer-related projects*

Include the funding organization and your role on the project

If you do not have any pending or unfunded cancer-related projects, please write "N/A"

List any current Massey Comprehensive Cancer Center faculty collaborations*

If you do not have any MCCC collaborations, please write "N/A"

List any current inter-institutional collaboration(s)*

Please include the name of their home institution(s)

If you do not have any inter-institutional collaborations, please write "N/A"

List any current global faculty collaboration and the associated country*

If you do not have any global collaborations, please write "N/A"

List any leadership participation in cancer-related committees and organizations*

Include committee name, parent organization, and your role

If you are not a part of any committees and organizations, please write "N/A"

Which of the following Massey Research Program(s) would be a good fit for you?*

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Have you discussed joining a program with a MCCC Program Leader(s)?*

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Biosketch and CV Upload*

Recent biosketch that follows NIH guidelines

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By submitting this application, I acknowledge that upon approval of my membership, I am expected to contribute to the mission and growth of the Cancer Center through support of Cancer Center activities. The responsibilities of membership include:*

Work with other Massey members to develop programmatic and interdisciplinary research that further the scientific goals of the Cancer Center and lead to collaborative publications and research grants.

Participate in cancer center events including research program meetings, retreats, seminars, committees and disease working group meetings.

Review grant applications received under Massey's intramural grant programs if asked to do so.

Acknowledge Massey, use of center space, use of Massey shared resources, and other support from the center in cancer-related publications and presentations.

Participate in the Cancer Center Support Grant (CCSG) application process to the NCI.

Participate in Masseys Faculty Development Program.

Participate actively in the Massey's education efforts, including appropriate symposia, cancer center curricula for fellows, graduate students and postdoctoral students, as well as undergraduate programs and community education.

Provide updated research information and progress, clinical trials information and accruals, other support, publications, CVs, and biosketches as requested, but no less than annually, in order to ensure that administration is up to date on all information needed for various reporting requirements

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Send me a copy of my responses

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