Form 1 ODS DSRP Registration form

Dietary Supplement Research Practicum: Registration

OMB#: 0925-0740 Exp Date: 07/31/2022 Registration Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0740). Do not return the completed form to this address. Please confirm your participation for the practicum below. Select the option that applies:   Select at least one option. YES, I plan to attend the Mary Frances Picciano Dietary Supplement Research Practicum in Bethesda, Maryland, June 10-12, 2020. NO, I will not attend the Mary Frances Picciano Dietary Supplement Research Practicum in Bethesda, Maryland, June 10-12, 2020. Please note: All fields are required unless otherwise noted.
Optional National Institutes of Health (NIH) Clinical Center Tour At the conclusion of this year’s practicum, on Friday, June 12, we are pleased to offer optional tours. To register for a tour, please indicate your selection below. Yes, I plan to participate in the optional tour of the NIH Clinical Center after the practicum concludes on Friday, June 12. A bus will take you to Building 10, and the tour will include: An overview of the NIH Clinical Center and its protocols A walking tour of the Clinical Center An overview and walking tour of the Metabolic Clinical Research Unit (specializes in the study of metabolism and obesity; includes indirect calorimetry rooms) and the Metabolic Kitchen within the Clinical Center. The tour is scheduled from 1:30 p.m. to about 2:45 p.m. Yes, I plan to participate in the optional tour of the National Library of Medicine (NLM) after the practicum concludes on Friday, June 12. The tour, which originates in the NLM Visitor Center (Room 127, Building 38A), includes: An 8-minute video providing an overview of NLM programs and services Brief demonstrations of the library’s online information resources A walking tour that includes the computer room, reading room, exhibition area, and the History of Medicine Division. The tour is scheduled from 1:30 p.m. to 2:45 p.m. No, I do not plan to participate in a tour.
Contact Information Please provide your information as requested below for practicum materials (e.g., name tags, attendee list).
Salutation (optional)
First Name	Enter First Name. First Name field contains invalid characters: < > ; & ^ # ~ ` | \. Please remove. Maximum allowed characters = 150 in the First Name field.
Last Name	Enter Last Name. Last Name field contains invalid characters: < > ; & ^ # ~ ` | \. Please remove. Maximum allowed characters = 150 in the Last Name field.
Suffix (optional)
Affiliation (Institution/Company)	Maximum allowed characters = 100 in the Affiliation field.
Title or Position	Click or tap here to enter text. For example: Assistant Professor, Postdoctoral Research Associate, Registered Dietitian
Email	Enter Email. Enter a valid email address. Maximum allowed characters = 150 in the Email field.
Confirm Email (Please re-type your email address here)

Accommodations:

Individuals with disabilities who need reasonable accommodation or who may require sign language to participate in this event should contact [email protected] or call (240) 453-2695. Requests should be made at least 10 days in advance of the event.

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