YALE CANCER CENTER
333 Cedar Street, Suite WWW 205, New Haven, CT 06520-8028
CLINICAL MEMBERSHIP APPLICATION
NAME:
ACADEMIC TITLE:
DEPARTMENT:
SECTION:
MAILING ADDRESS:
E-MAIL ADDRESS:
TELEPHONE:
FAX:
UPI#: _____________________ eRA Commons ID: _______________________________
YALE EMPLOYMENT START DATE: _________________
ADMIN ASST or SECONDARY CONTACT (in case of urgent YCC need):
NAME: ____________________________________________________________________
EMAIL: ______________________________ TEL: _________________________________
UPI: _____________________ (Unique ID number found on your Yale Directory listing)
YCC RESEARCH PROGRAM AFFILIATION
(See following list of Research Programs on page 4 and choose one to join):
Program Leader
Applicant Signature/Date
Name:
Signature:
Complete this and the attached forms using additional pages as needed. Please provide:
1.
An overall description of your cancer-related activities in the last four years, including
cancer-related research and publications;
A listing of cancer-related teaching activities;
A listing of cancer-related national/community service (study sections, consultation
to NCI, voluntary assistance to cancer organizations, etc.);
4.
A listing of all grant support for the last five years and a listing of pending applications.
Include grant number and, if appropriate, funding source, project title, role in project,
percent effort, period of award, and annual direct costs;
5.
A current curriculum vitae and bibliography;
6.
An NIH-formatted Biosketch
Return all documents to christina.dreyfus@yale.edu or P.O. Box 208028, 333 Cedar Street,
New Haven, CT 06520.
2.
3.
Checklist:
[ ] Signed Application Form
[
[
[
[
]
]
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]
Curriculum Vitae & Bibliography
NIH Formatted Biosketch
Description of cancer-related research and activities
Letter from Program Leader with signature
January 2016
Page 1
Clinical Members are individuals who do not meet the criteria for Full Membership, but
who meaningfully contribute to the activities of the YCC. Clinical Members typically hold
a clinical appointment and actively treat patients.
Eligibility
Clinical Members must:
1. Be affiliated with the Yale School of Medicine
and
2. Provide substantive clinical, scientific, or administrative expertise to the overall research
mission of the YCC.
In addition, Clinical Members should:
1. Contribute to the peer-reviewed cancer literature
or
2. Participate on an extramural cancer-relevant peer-reviewed grant
or
3. Contribute to YCC intervention (therapeutic or non-therapeutic) cancer clinical trials
Expectations
Clinical Members are encouraged to:
1.
2.
3.
4.
Participate in clinical, population science and/or laboratory cancer research;
Participate in Center, program or disease unit meetings, retreats, and symposia;
Participate in Center internal review panels and other committees;
Submit in a timely and accurate manner, annual and special requests for updates on
Research Progress, Other Support, Publications, Curriculum Vitae and Biosketches;
5. List YCC affiliations on curricula vitae and biosketches;
6. Acknowledge membership and YCC support, in publications, abstracts, posters, and
presentations.
Privileges
Clinical Members will be entitled to receive:
1.
2.
2.
3.
4.
5.
6.
Ability to apply for Pilot Grants with a Full YCC member as co-PI;
Access to YCC administrative resources and personnel;
Enhanced opportunities to develop collaborative research efforts;
Facilitated access to clinical populations for clinical research studies;
YCC publications, announcements of availability of clinical awards and grants;
Public Relations support;
Invitation to YCC lectures, Grand Rounds, meetings and disease team conclaves.
January 2016
Page 2
Application Process
1. For questions please contact Edward Snyder, Chair of the Membership Committee at (203)
688-2441, edward.snyder@yale.edu; or Christina Dreyfus, Yale Cancer Center Program
Coordinator at (203) 737-8375 or christina.dreyfus@yale.edu.
2. Each applicant must submit:






A fully completed, signed application form;
A curriculum vitae including bibliography;
An NIH-formatted Biosketch;
A description of the applicant’s cancer-related activities. The cancer focus of the
applicant’s activities and its relation to the mission of the YCC should be made
clear in the description;
A listing of any cancer-related grant support;
A written paragraph of support from the applicable Research Program leader.
3. Send 1 copy of the completed and signed application to Christina Dreyfus at
christina.dreyfus@yale.edu or P.O. Box 208028, 333 Cedar Street, New Haven, CT 06520.
4. The Chair of the YCC Membership Committee will review and approve all applications.
5. The Chair of the YCC Membership Committee will notify applicants of the decision by letter.
6. Clinical Membership can be maintained as long as the individual fulfills the criteria necessary
for the initial appointment. All YCC members will have their membership status reviewed at least
every 2 years.
January 2016
Page 3
YALE CANCER CENTER
RESEARCH PROGRAMS
YCC PROGRAM
PROGRAM LEADERS
Genomics, Genetics and Epigenetics
Lajos Pusztai, M.D., D.Phil.
Marcus Bosenberg, M.D., Ph.D.
Cancer Immunology
Lieping Chen, M.D., Ph.D.
Madhav Dhodapkar, M.B.B.S.
Cancer Prevention and Control
Melinda Irwin, Ph.D.
Xiaomei Ma, Ph.D.
Developmental Therapeutics
Karen Anderson, Ph.D.
Barbara Burtness, M.D.
Virus and Other Infection-Associated
Walther Mothes, Ph.D.
Cancers
Wendell Yarbrough, M.D.
Radiobiology and Radiotherapy
Peter Glazer, M.D., Ph.D.
Joann Sweasy, Ph.D.
Signal Transduction
David Stern, Ph.D.
Daniel Petrylak, M.D.
January 2016
Page 4
YALE CANCER CENTER
CLINICAL MEMBERSHIP APPLICATION
PROGRAM LEADER LETTER OF SUPPORT
To be completed by Research Program Leader
Provide a paragraph to substantiate why Program membership is appropriate.
Name of Applicant: _____________________________________________________
Research Program: _____________________________________________________
January 2016
Page 5
YALE CANCER CENTER
CLINICAL MEMBERSHIP APPLICATION
APPLICANT STATEMENT- CANCER-RELATED RESEARCH FORM
Provide a general description of your cancer-related research and activities.
IMPORTANT: Please highlight three key words that can be used for indexing.
Name of Applicant: ____________________________________________________
Research Program: ____________________________________________________
Key words:
1)
2)
3)
1. An overall description of your cancer-related activities in the last four years,
including cancer-related research and publications
2. A listing of cancer-related teaching activities
3. A listing of cancer-related national/community service (study sections,
consultation to NCI, voluntary assistance to cancer organizations, etc.)
4. A listing of all grant support for the last five years and a listing of pending
applications. Include grant number and, if appropriate, funding source, project
title, role in project, percent effort, period of award, and annual direct costs.
January 2016
Page 6