Form 1 Registration

EVENT REGISTRATION

OMB Number: 0925-0299
Expiration Date: 30 May 2024
Burden Time: 3 minutes
Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights of participants are protected by The Privacy Act of 1974.
Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. The information collected in this study will be
kept private to the extent provided by law. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all
participants and reported as summaries.
Public reporting burden for this collection of information is estimated to average 3-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 0925-0299. Do not return the completed form to this address.

CONTACT INFORMATION
Q1 Badge ID:
________________________________________________________________

Q2 ORC ID
________________________________________________________________
Q3 Greeting Title:
o
o Mr.
o Ms.
o Mx.
o Dr.
Q4 First Name (Given Name):
________________________________________________________________

Q5 First Name (Preferred Name):
________________________________________________________________

Q6 Last Name (Family Name):
________________________________________________________________
Q7 Email Address (check accuracy):
________________________________________________________________

Q8 Phone Number (check accuracy):
________________________________________________________________

Q9 Position Title:
________________________________________________________________

Page 1 of 5

Q10 LinkedIn
________________________________________________________________
Q11 Is this person the point of contact (Yes/No)?
o Yes
o No
INSTITUTION OR ORGANIZATION INFORMATION
Q12 Institution or Organization Name
________________________________________________________________
Q13 Program or Department Name
________________________________________________________________

Q14 Program Name for Publication Materials
________________________________________________________________

Q15 Type of Program
________________________________________________________________

Q16 Address or Location
________________________________________________________________

Q17 Website URL
________________________________________________________________

Page 2 of 5

EDUCATIONAL OR TRAINING INFORMATION
Q18 NIH Institute-Center
o CC
o CIT
o CSR
o FIC
o NCATS
o NCCIH
o NCI-CCR
o NCI-DCEG
o NEI
o NHGRI
o NHLBI
o NIA
o NIAAA
o NIAID
o NIAMS
o NIBIB
o NICHD
o NIDA
o NIDCD
o NIDCR
o NIDDK
o NIEHS
o NIGMS
o NIMH
o NIMHD
o NINDS
o NINR
o NLM
o OD
Q19 NIH Campus
o Bethesda, Maryland (main campus)
o Baltimore, Maryland
o Frederick, Maryland
o Gaithersburg, Maryland
o Poolesville, Maryland
o Rockville, Maryland
o Framingham, Massachusetts
o Research Triangle Park, North Carolina
o Hamilton, Montana
o Phoenix, Arizona
o other

Page 3 of 5

Q20 Educational Status or Training Program
o Summer Intern
o Postbaccalaureate
o Graduate Student (master degree)
o Graduate Student (doctoral degree)
o Medical Student
o Dental Student
o Postdoctorate: IRTA / CRTA
o Postdoctorate: Clinical Fellow
o Postdoctorate: Research Fellow
o Postdoctorate: Visiting Fellow
o Staff Clinician
o Staff Scientist
o NIH Investigator
o NIH Training Director
o NIH Staff
o OITE Staff
Q21 Highest Education Degree you have been awarded or will be being awarded:
▢ High School Graduate (diploma or equivalent)
▢ Some college but no degree
▢ Associate Degree (2-year)
▢ Bachelor Degree (BA or BS)
▢ Master Degree (MA, MS, MEd)
▢ Doctorate or Advanced Professional Degree (PhD, JD, MD, EdD, DDS, DVM)
▢ Other

Q22 What is your educational year?
o Graduate
o First Year
o Second Year
o Third Year
o Fourth Year
o Fifth Year
o Greater than Fifth Year

Page 4 of 5

Q23 What is your educational major?
o Biochemistry and Biophysics
o Biomedical and Bioengineering
o Bioinformatics
o Biology
o Cell and Molecular Biology
o Chemistry
o Computer Science
o Data Science
o Environmental Science
o Engineering
o Epidemiology
o Genetics
o Humanities and the Arts
o Immunology
o Information Science
o Mathematics
o Medicine (Pre-Med)
o Microbiology
o Neuroscience
o Nursing
o Nutrition
o Pharmaceutical Sciences
o Physics
o Physiology
o Psychology
o Public Health
o Veterinary Medicine (Pre-Vet)
o Virology
o Zoology
o Undeclared
Q24 NIH Mentor / Investigator
________________________________________________________________

Q25 University Mentor / Professor
________________________________________________________________

EVENT OR MEETING DETAILS
Q26 Format type
o In-Person
o Virtual
o Hybrid
Q27 How will you participate?
▢ Oral presentation
▢ Panel Discussion
▢ Breakout Session

Q28 How did you learn about this program or event?
________________________________________________________________

Page 5 of 5