Form 1 Sexual Gender Minority Research Office Regional Workshop

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
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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
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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)

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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)

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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
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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

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2/4/2020

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

Submit Registration

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

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