Name of Cardiologist
Phone Number of Cardiologist
Administrative Contact Person
Phone of Key Administrative
Name of Institution
How would you describe your institution?
Is your C-O program a dedicated C-O clinic?
How long has your cardio-oncology program been in operation?
On average how many C-O patients do you see each month?
Greater than 100
Do you have any training program in C-O at your institution?
Have you become a member of IC-OS?
Did you take the IC-OS Certifying exam or did anyone at your practice?
What hematology/oncology or other subspecialties are regularly engaged with the C-O team (list the top 5)?
Hematology, Oncology, Radiation Oncology, Nursing leadership, Hospital Administration, Electrophysiology, Interventional Cardiology, Cardiac Imaging, Nuclear medicine, Radiology, Cardiomyopathy/Heart Failure, Arrhythmia including QT prolongation, Cancer Survivorship, Pre-chemotherapy or stem cell evaluation, Hypertension