1 Sexual Gender Minority Research Office Regional Workshop

Conference, Meeting, Workshop, and Poster Session Registration Generic Clearance (OD)

Sexual Gender Minority Research Office Regional Workshop the Equitas Health Institute - Registration

OMB: 0925-0740

Document [pdf]
Download: pdf | pdf
2/4/2020

Sexual & Gender Minority Research Office Regional Workshop & the Equitas Health Institute - Registration

Registration
Registration deadline XX day, Month XX, 2020
OMB Number: 0925-0740 Exp Date: 07/31/2022
Public reporting burden for this collection of information is estimated to average 5-minutes per submission. 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 0925-0648. Do not return the completed form to this address.
Please note: Only fields with an * are required unless otherwise noted.

* First Name

* Last Name

Pronoun(s)

Fill in the blank.
* Email

* Phone

Enter a valid U.S. or International number format
Degree
None
Ph.D.
Pharm.D.
Dr.P.H.
Dr.Ed.
D.D.S.
M.P.H.
M PP
TIP: Hold the CTRL/Command key while clicking to select more than one degree
Other Degree

2/4/2020

Sexual & Gender Minority Research Office Regional Workshop & the Equitas Health Institute - Registration

If "other" please specify
Years since you completed most recent degree
1-2
3-5
5-10
10 or more
* Address 1

Address 2

* City

* State

* Zipcode

Are you currently supported by NIH funding?
Yes
No
N/A (NIH Staff)
If yes, what type of NIH funding do you currently have?
R-series
K-series
F-series
Other (please specify)
Other

If yes, what is your role on the NIH grant(s) that support your salary? (all that apply)

https://www.scgcorp.com/sgmroregwkspohio2020/Registration

2/4

2/4/2020

Sexual & Gender Minority Research Office Regional Workshop & the Equitas Health Institute - Registration

PI / Co-PI
Co-Investigator
Consultant
Mentor
Other research role
Other (please specify)

TIP: Hold the CTRL/Command key while clicking to select more than one
Other

Do you plan to submit a new application for NIH funding?
Yes, within the next 1 - 2 years
Yes, more than two years from now
No
N/A (NIH Staff)
Which of these NIH institutes and centers do you plan to apply to or currently receive funding from?
(all that apply)
FIC
NCCAM
NCI
NCMHD
NCRR
NEI
NHGRI
NHLBI
TIP: Hold the CTRL/Command key while clicking to select more than one
Describe your area of research.

Describe your populations of interest.

Type of registration requested for this workshop.
Student
Postdoc
Research Investigator
Invited Presenter or Moderator
NIH Representative

https://www.scgcorp.com/sgmroregwkspohio2020/Registration

3/4

2/4/2020

Sexual & Gender Minority Research Office Regional Workshop & the Equitas Health Institute - Registration

Submit Registration

This site is created and hosted by The Scientific Consulting Group, Inc.

https://www.scgcorp.com/sgmroregwkspohio2020/Registration

4/4


File Typeapplication/pdf
File Modified2020-02-04
File Created2020-02-04

© 2024 OMB.report | Privacy Policy