Partnering On Education Tools (POET)

Partner Interest Form

Directions: Complete STEPS 1-4 to let us know about your organization and your interest in partnering on the OESI programs listed below. Don't forget to click SUBMIT when you're done to send us this online form. OESI will contact you to discuss if there are appropriate opportunities for collaboration.

STEP 1. Please tell us about yourself.
* Required fields
Prefix:
Contact name: *
Job title:
Organization name: *
Organization address: *
Organization phone: *
Organization fax:
Organization e-mail:
Organization Web site:
Contact direct e-mail: *
Contact direct phone: *

STEP 2. Please tell us about your organization. Tell us about your organization: (for example, "OESI develops, implements, and evaluates cancer education programs for patients, health professionals, and advocates on topics across the cancer continuum"): *


Type of organization: *	Please choose the best fit from the below types
If "Other", please choose from these options:

Audience served: * (check all that apply)	Adult Patients/Survivors Pediatric Patients/Survivors Family members/caregivers Oncology Health professionals General Health Professionals Federal agencies Advocates

Special Population Focus: (check all that apply)	American Indian or Alaska Native African American Hispanic or Latino Native Hawaiian or other Pacific Islander Medically Underserved Filipino Chinese Vietnamese Japanese Korean Other

STEP 3. Check programs that are of interest to your organization and in which you may want to partner.

To learn more about the program before deciding, click on the title. (Select the "Back" button to return to this form).

Assuring Literacy Across Cancer Content
Breast Cancer Education Program
Caregiver Education
Cervical Cancer Education Program
Clinical Trials
Facing Forward Survivor Series
NCI Body & Soul Dissemination Program
Pain Management
Palliative Care Patient Education
Patient Navigation Research Program
Prostate Health Education Program
Ride On Printing
Understanding Changes Series

STEP 4:

Thank you for your interest and time.