Form 1 MicroLab Registration

AI / Ethics Microlab Registration
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OMB Control Number: 0925-0740
Expiration Date: 7/31/2022
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this address.

How did you hear about this event? *

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Select from a drop down list:
Website
Newsletter
Social Media
Listserv
Word of Mouth
Other

Personal Information
First Name *

Last Name *

email *
This will be the primary means of communication with you regarding this event.

ORCID ID

Organization Information

What sector best describes your work? *
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Academic

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Federal Observer

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Government

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Industry

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Other

University / Organization Affiliation *

Department/Division *

Please select any of these Minority Serving Institution (MSI) designations as they apply to
your University? *
Please refer here for additional information:
https://www.doi.gov/pmb/eeo/doi-minority-serving-institutions-program

HBCU

HSI

TCU

AAPISI

City *
State/Territory *

Select from dropdown list of states and territories
Country *

Select or enter information
Postal Code *

Professional Information
Job Title *
Career Level *
Early Career

Mid Career

What is your primary area of expertise *
Please select all that apply
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Biomedical and Behavioral Scientists

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Biomedical Ethicists

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Computer and Data Scientists

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Health or Tech Policy

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Health or Tech Law

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Health or Patient Advocates

Late Career

N/A

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Industry

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Social and Ethical Impacts of Tech/AI/ML

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Social Scientists

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Technologists, Artists, and Storytellers

What are you secondary area(s) of expertise *
Please select all that apply
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Biomedical and Behavioral Scientists

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Biomedical Ethicists

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Computer and Data Scientists

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Health or Tech Policy

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Health or Tech Law

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Health or Patient Advocates

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Industry

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Social and Ethical Impacts of Tech/AI/ML

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Social Scientists

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Technologists, Artists, and Storytellers

Application Questions
Why are you interested in this Micro Lab? *

What do you hope to contribute to this Micro Lab? *

What do you hope to gain from participating in this Micro Lab? *
Do you consider yourself an underrepresented voice in this space?
optional
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Yes

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No

If yes, why?
optional

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Send me a copy of my responses