Document
OMB-F14 - Event Registration
ICR 202608-0925-001 · OMB 0925-0299 · Object 171714000.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | OMB-F14 - Event Registration |
| Author | Qualtrics |
| Last Modified By | Writer |
| File Modified | 2026-08-12 |
| File Created | 2026-08-14 |
| Conversion State | complete |
Extracted Text
EVENT REGISTRATION
OMB Number: 0925-0299
Expiration Date: 31 March 2027
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. Completion of this collection form is voluntary and there are no penalties for not participating or withdrawing at any time. The collection information will be kept private to the extent provided by law. Information provided will be covered by the following SORNs: OPM/GOVT-1, OPM/GOVT-5, 09-90-0020, 09-25-0014, 09-25-0108, 09-25-0140, 09-25-0158, and 09-25-0165.
Public reporting burden for this collection of information is estimated to average 3 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 (0925-0299). Do not return the completed form to this address.
NAME INFORMATION
1. Badge ID:
2. ORC ID
3. Greeting Title:
• <no response>
• Mr.
• Ms.
• Dr.
• Other, please specify:
4. First Name (Given Name):
5. First Name (Preferred Name):
6. Last Name (Family Name):
ADDRESS INFORMATION
7. Email Address (check accuracy):
8. Phone Number (check accuracy):
9. LinkedIn
10. Is this person the point of contact (Yes/No)?
• Yes
• No
11. Address Information
• Street:
• Building:
• Room:
• City:
• State:
• Zip Code:
• Country:
INSTITUTION OR ORGANIZATION INFORMATION
12. Institution or Organization Name
13. Program or Department Name
14. Program Name for Publication Materials
15. Position Title
16. Type of Program
• Dental
• Graduate – PhD
• Graduate – MS
• Medical (MD)
• Medical (DO)
• MD/PhD
• Pharmacy
• Psychology
• Public Health
• Other, specify:
17. Website URL
EDUCATIONAL OR TRAINING INFORMATION
18. NIH Institute-Center
☐ CC ☐ CIT ☐ CSR ☐ FIC ☐ NCATS
☐ NCCIH ☐ NCI-CCR ☐ NCI-DCEG ☐ NEI ☐ NHGRI
☐ NHLBI ☐ NIA ☐ NIAAA ☐ NIAID ☐ NIAMS
☐ NIBIB ☐ NICHD ☐ NIDA ☐ NIDCD ☐ NIDCR
☐ NIDDK ☐ NIEHS ☐ NIGMS ☐ NIMH ☐ NIMHD
☐ NINDS ☐ NINR ☐ NLM ☐ OD
19. NIH Campus
☐ Bethesda, Maryland (main campus)
☐ Baltimore, Maryland
☐ Frederick, Maryland
☐ Gaithersburg, Maryland
☐ Poolesville, Maryland
☐ Rockville, Maryland
☐ Framingham, Massachusetts
☐ Research Triangle Park, North Carolina
☐ Hamilton, Montana
☐ Phoenix, Arizona
20. Educational Status or Training Program
• Undergraduate Scholarship Program (UGSP)
• Summer Internship Program (SIP)
• Postbaccalaureate Program (PBP)
• Graduate Student (Master Degree)
• Graduate Student (Medical Student)
• Graduate Student (Dental Student)
• Graduate Student (Doctoral Degree: PhD or Equivalent)
• Postdoctorate: IRTA / CRTA
• Postdoctorate: Clinical Fellow
• Postdoctorate: Research Fellow
• Postdoctorate: Visiting Fellow
• Staff Clinician
• Staff Scientist
• NIH Investigator
• NIH Training Director
• NIH Staff
• OITE Staff
21. How many years have you been at the NIH?
☐ < 3 months ☐ 3–6 months ☐ 6–9 months ☐ 9-12 months
☐ 12-15 months ☐ 15-18 months ☐ 18-21 months ☐ 21-24 months
☐ 24-27 months ☐ 27-30 months ☐ 30-33 months ☐ 33-36 months
☐ 36-39 months ☐ 39-42 months ☐ 42-45 months ☐ 45-48 months
☐ 48-51 months ☐ 51-54 months ☐ 54-57 months ☐ 57-60 months
☐ other, specify_____
22. Highest Education Degree you have been awarded or will be awarded (select all that apply):
• 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)
• Medical Degree (MD)
• Medical Degree (OD)
• Dental Degree (DDS)
• Veterinary Degree (DVM)
• Juris Doctor Degree (JD)
• Doctorate Degree (PhD or DPhil)
• Other, specify:
23. What is your educational year?
◦ Graduate
◦ First Year
◦ Second Year
◦ Third Year
◦ Fourth Year
◦ Fifth Year
◦ Greater than Fifth Year
24. What is your educational major?
☐ Biochemistry and Biophysics ☐ Biomedical and Bioengineering
☐ Bioinformatics ☐ Biology
☐ Cell and Molecular Biology ☐ Chemistry
☐ Computer Science ☐ Data Science
☐ Environmental Science ☐ Engineering
☐ Epidemiology ☐ Genetics
☐ Humanities and the Arts ☐ Immunology
☐ Information Science ☐ Mathematics
☐ Medicine (Pre-Med) ☐ Microbiology
☐ Neuroscience ☐ Nursing
☐ Nutrition ☐ Pharmaceutical Sciences
☐ Physics ☐ Physiology
☐ Psychology ☐ Public Health
☐ Veterinary Medicine (Pre-Vet) ☐ Virology
☐ Zoology ☐ Undeclared
25. NIH Mentor / Investigator:
• Greeting Title:
• First Name:
• Last Name:
• Email Address:
26. University Mentor / Professor
• Greeting Title:
• First Name:
• Last Name:
• Email Address:
EVENT OR MEETING DETAILS
27. How will you attend this event?
• In-Person
• Virtual
• Hybrid
28. How will you participate?
• Oral presentation
• Panel Discussion
• Breakout Session
29. Select your preferred exhibit session:
• Morning (9:00am – 12:30pm ET)
• Afternoon (1:30pm – 5:00pm ET)
• No preference
30. Where are you located?
• <List of US States>
• <List of US Territories>
• <List of Countries>
31. How did you learn about this program or event?
• <List of Source Options>