Contact Name

Address:

City:

State:

Zip Code:

Email Address:

Telephone Number:

equired)

Name of Organization:

Brief Description of Project:

Rationale for Project:

Potential Partners for Implementation:
List Name(s) and Contact Information

Estimated Timeline:

Estimated Budget:
Include costs associated with
staffing, equipment, supplies
and meeting expenses.

Suggestions for Funding Sources:

Type of WCC Membership:

Not a Member

Organizational Member

Affiliate Member

Individual Member

Please choose the WI CCC chapter(s) and priority(ies) below you feel relates most to your proposed project.

Chapter 1: Prevention

Priority A: Decrease tobacco use and exposure to tobacco smoke.

Priority B: Promote healthy lifestyles through nutrition and physical activity.

Priority C: Promote and encourage protective behaviors from sun and UV exposure.

Chapter 2: Screening and Detection

Priority A: Increase colorectal screening rates for those 50 years and older, especially in high-risk populations.

Priority B: Increase rates of breast cancer screening, especially in high-risk populations.

Priority C: Increase rates of cervical cancer screening, especially in high-risk populations.

Priority D: Increase prostate cancer screening rates for men 50 years and older, especially in high-risk populations.

Chapter 3: Treatment

Priority A: Increase access to cancer treatment by reducing economic, geographic, cultural, and systems barriers.

Priority B: Encourage adherence by physicians to cancer treatment guidelines.

Priority C: Increase awareness of and participation in cancer clinical trials.

Chapter 4: Quality of Life

Priority A: Increase reimbursement for services related to quality of life at time of diagnosis and throughout the cancer continuum.

Priority B: Provide education that will enhance the understanding of the importance of quality of life in the treatment continuum.

Priority C: Assemble data on quality of life to establish best practices in measuring optimal treatment outcomes.

Chapter 5: Palliative Care / End of Life Issues

Priority A: Increase access to palliative care.

Priority B: Provide education that will enhance the understanding of palliative care in the treatment continuum.

Priority C: Identify best practices for delivering palliative care.

Chapter 6: Data Collection and Reporting

Priority A: Promote the collection and use of information to increase professional and public understanding and education about cancer and its impact on Wisconsin residents.

Priority B: Increase timeliness of reporting cancer cases to Wisconsin Cancer Reporting System.

Priority C: Improve the quality and completeness of treatment data.

Priority D: Improve racial and ethnic cancer data collection.