| Attachment 15 - eRA Commons Person Profile Data | |||
| Currently Collected on OMB Cleared Forms | |||
| OMB Clearance # 0925-0001 | |||
| Field Name | Req Opt |
Type of Field | LOV or Notes |
| Name and ID | |||
| Name Prefix | O | Text | |
| First Name | R | Text | |
| Middle Name or Initial | O | Text | |
| Last Name | R | Text | |
| Name Suffix | O | Text | |
| eRA Email | R | Text | |
| ORCHID ID | R | Text | Will be a data feed from another system |
| IDENTIFICATION | |||
| DOB (Include DNWTP option) |
R | Date | DNWTP check provided |
| SSN (full or last 4) | O | Text | |
| CITIZENSHIP STATUS | |||
| Citizenship Country | R | LOV | Country List |
| Status in the United States | R | Radio Buttons | US Citizen or Non-citizen National Permanent Resident of US Non-U.S. Citizen w/a temporary U.S. Visa Non-U.S. Citzen--Not Residing in the U.S. |
| DEMOGRAPHICS | |||
| Gender | R | Radio Buttons | Female Male DNWTP |
| Ethnicity and Race | |||
| Ethnicity | R | Radio Buttons | Hispanic/Latino Non-Hispanic DNWTP |
| Race | R | Checkboxes | American Indian or Alaska Native >>Tribal Affiliation <text box> Asian Black or African American Native Hawaiian or Pacific Islander White DNWTP |
| Disability | |||
| Do you have? | R | Y/N | |
| Type of Disability (Check all that apply) | R | Checkboxes | Vision Hearing Mobility/Orthopedic Other DNWTP |
| TRAINING AND CAREER DEVELOPMENT SPECIFIC DATA | |||
| Non-Deliquency on US Federal Debt? | R | Radio Buttons | No Yes |
| Text Entry field if Yes | Text | ||
| Disadvantaged Background? | R | Radio Buttons | No Yes DNWTP Not Applicable to me (not an undergraduate) |
| EMPLOYMENT | |||
| Add a New Job | |||
| Employer: Select one: | R | ||
| I work in a company or institution outside NIH | Radio Button | When selected an LOV of organizations registered in the eRA Commons is available to select from | |
| I work inside NIH | Radio Button | When selected, a LOV of NIH ICs is available | |
| Start Date | R | Date | |
| End Date | O | Date | |
| Job Title | O | Text | |
| About This Job | |||
| Primary Employment? | R | Checkbox | |
| R | Radio Button | Full-Time Part-Time |
|
| This is a job working directly for the federal government. | R | Radio Button | Yes No |
| This is a faculty teaching position. | O | Checkbox | If Checked, then the following Academic Rank LOV is used |
| Academic Rank | O | LOV | Assistant Professor Associate Professor Instructor Other Professor |
| This is an academic administrative position. | O | Checkbox | If Checked, then the following Position LOV is used |
| Position | O | LOV | Assistant or Associate Dean Chairperson of Dept (or Director) Dean Other President Vice President |
| Addresss & Contact Information | |||
| R | Text | ||
| Phone | R | Text | |
| Street Address Line 1 | R | Text | |
| Street Address Line 2 | O | Text | |
| City | R | Text | |
| State | R | LOV | State List |
| ZipCode | R | Text | |
| Country | R | LOV | Country List |
| Reviewer Information | |||
| What address should NIH use to contact you for reviews? | Radio Button | Options: Use my work address Use my home address |
|
| Provide a different address If checked | |||
| Different Address | |||
| Street Address | R | Text | |
| City | R | Text | |
| State | R | LOV | |
| ZipCode | R | Text | |
| Country | R | LOV | Country List |
| Home Address | |||
| Street Address | R | Text | |
| City | R | Text | |
| State | R | LOV | State List |
| ZipCode | R | Text | |
| Country | R | LOV | Country List |
| Eligibility for Continuous Submission | LOV | LOV updated annually. Current values are: Eligibility Period: 08/16/2012 – 09/30/2013 Eligibility Period: 08/16/2013 – 09/30/2014 Eligibility Period: 08/16/2014 – 09/30/2015 |
|
| TRAINEE PERMANENT ADDRESS | |||
| Street Address | R | Text | |
| City | R | Text | |
| State | R | LOV | State List |
| ZipCode | R | Text | |
| Country | R | LOV | Country List |
| R | Text | ||
| Phone | R | Text | |
| EDUCATION | |||
| Degrees | |||
| Degree Name | R | LOV | See separate Tab for LOV |
| Degree Text (for Other) | O | Text | |
| Status: | Radio Buttons | ||
| Degree Completed | R | Radio Buttons | w/Corresponding Date Field |
| In Progress, expected | Radio Buttons | w/Corresponding Date Field | |
| Length of Program (# of Yrs) | O | LOV | 1 - 9 Years |
| Institution | R | Text | |
| Location (if not in US, indicate city & country) | O | Text | |
| Is this your Terminal Research Degree? | O | Checkbox | |
| Area of Study-Primary | O | Text | |
| Area of Study-Secondary | O | Text | |
| Area of Residency |
O | Text | |
| Residency Date Completed or Expected |
R | Date | |
| System Generated Fields | |||
| Fields used to aid in NI/ESI efforts. All are system-generated but part of the Person Profile | |||
| ESI Eligibility | Yes/No | ||
| End of Eligibility Date | Date | ||
| New Investigator Eligibility | Yes/No | ||
| Appeal Date | Date | ||
| Appeal Outcome | Text | ||
| Standard NI/ESI Eligibility is system calculated. However an exception policy has been implemented. These exceptions are handled via an appeal process. | |||
| Reference Ltrs | |||
| Referee First Name | R | ||
| Referee Last Name | R | ||
| Referee MI Name | O | ||
| Referee eMail | R | ||
| Referree Institution/Affliation | R | ||
| Referree Department | R | ||
| PI Commons User ID | R | ||
| PI Last Name | R | ||
| FOA Number | R | ||
| Reference Letter Confirmation # (if re-submitting) | O | ||
| Degrees LOV in Person Profile | |
| AB | BACHELOR OF ARTS |
| BA | BACHELOR OF ARTS |
| BOTH | OTHER BACCALAUREATE |
| BS | BACHELOR OF SCIENCE |
| BSN | BACHELOR OF SCIENCE IN NURSING |
| DC | DOCTOR OF CHIROPRACTIC |
| DDOT | OTHER DOCTOR OF MEDICAL DENTISTRY |
| DDS | DOCTOR OF DENTAL SURGERY |
| DMD | DOCTOR OF MEDICAL DENTISTRY |
| DNSC | DOCTOR OF NURSING SCIENCE |
| DO | DOCTOR OF OSTEOPATHY |
| DOTH | OTHER DOCTORATE |
| DPH | DOCTOR OF PUBLIC HEALTH |
| DPM | DOCTOR OF PODIATRIC MEDICINE |
| DRPH | DOCTOR OF PUBLIC HEALTH |
| DSC | DOCTOR OF SCIENCE |
| DSW | DOCTOR OF SOCIAL WORK |
| DVM | DOCTOR OF VETERINARY MEDICINE |
| EDD | DOCTOR OF EDUCATION |
| ENGD | FOREIGN - DOCTOR OF ENGINEERING |
| FAAN | FELLOW OF THE AMERICAN ACADEMY OF NURSING |
| JD | DOCTOR OF JURIS PRUDENCE |
| MA | MASTER OF ARTS |
| MB | FOREIGN - BACHELOR OF MEDICINE |
| MBA | MASTER OF BUSINESS ADMINISTRATION |
| MBBS | FOREIGN - BACHELOR OF MEDICINE AND SURGERY |
| MD | DOCTOR OF MEDICINE |
| MDOT | OTHER DOCTOR OF MEDICINE |
| MLS | MASTER OF LIBRARY SCIENCE |
| MOTH | OTHER MASTERS |
| MPA | MASTER OF PUBLIC ADMINISTRATION |
| MPH | MASTER OF PUBLIC HEALTH |
| MS | MASTER OF SCIENCE |
| MSN | MASTER OF SCIENCE IN NURSING |
| ND | DOCTOR OF NATUROPATHY |
| OD | DOCTOR OF OPTOMETRY |
| OTH | OTHER |
| PHD | DOCTOR OF PHILOSOPHY |
| PHMD | DOCTOR OF PHARMACY |
| PSYD | DOCTOR OF PSYCHOLOGY |
| RN | REGISTERED NURSE |
| SCD | DOCTOR OF SCIENCE |
| VDOT | OTHER DOCTOR OF VETERINARY MEDICINE |
| VMD | DOCTOR OF VETERINARY MEDICINE |
| SAMHSA Reviewer Contact Information (RCI) form | |||
| Currently Collected on OMB Cleared Forms | |||
| OMB Clearance # 0930-0255 | |||
| This SAMHSA Reviewer section will only display if SAMHSA DGR staff manually mark the person as 'SAMHSA Reviewer' via Person Admin checkbox or similar (TBD). | |||
| Field Name | Req Opt |
Type of Field | LOV or Notes |
| <TBD category heading> | |||
| Past or Current Affiliation | O | Checkboxes | Limit 1: Community Based Organization Consultant Direct Treatment for Mental Health or Substance Abuse Faith Based Organization Federal, State, and County Government Substance Abuse Prevention Tribal Government Research University, Colleges, and Other Higher Education Systems Other <plus text field> |
| Do you identify as Transgender? | R | Radio Buttons | Yes No |
| Licensed Professional in Mental Health or Substance Use Disorder | O | Text | |
| Primary Expertise | |||
| Primary Expertise | O | Checkboxes | All that apply: Drug-Free Communities Substance Abuse Prevention Substance Abust Treatment Mental Health |
| Secondary Expertise | (maximum total of 5 over 3 categories) | ||
| A. Target Population | O | Checkboxes | Adolescents/High Risk Youth Consumer/Consumer Support Family Member of Consumer Disabled Families Infants and Children Homeless Military Women Seriously Mentally Ill Adults Veterans LGBTQ Other <plus text box> |
| B. Substance Abuse and Clinical Issues | O | Checkboxes | Alcohol Antisocial Behavior Crack/Cocaine Children's Mental Health Co-Occurring Substance Abust and Mental Health Depression/Manic Depression Eating Disorders Ecstasy Fetal Alcohol Syndrome Heroin HIV/AIDS Inhalants Marijuana Medical Treatment Methamphetamine Methadone Treatment Obsessive Compulsive Disorder Personality Disorders Post-traumatic Stress Prescription Drugs Psychotic Disorders Suicide Prevention |
| C. Other Expertise | O | Checkboxes | Counseling Drug Courts Criminal Justice Programs Faith Based Community Approaches Workplace Programs Coalition Building/Collaboration Health Information Technology Program Planning Management Research/Evaluation Residency Training (Medical) Training/Technical Assistance State Systems Violence Prevention Programs Integrated Care Other <plus text box> |
| Grant Review/Writing Experience | |||
| Grant Review/Writing Experience - provide specific information about your review history in the box(es) | O | Checkboxes/ Text |
Experienced SAMHSA Reviewer (Dates/No. of Reviews Completed) Experienced Federal Reviewer (Dates/Agency/No. of Reviews Completed) Experienced Non-Federal Reviewer (Dates/Agency/No. of Reviews Completed) No Review Experience |
| Include a brief paragraph summarizing your general expertise in relation to substance abuse treatment, substance abuse prevention, and mental health | O | Text | |
| Resume/CV | |||
| Resume/CV | R | Import | Ability to browse and attach file. |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |