Form 1 PASC online registration

2/20/2020

NCI Patient Advocate Steering Committee (PASC) Meeting - Registration Information | Online Registration by Cvent

NCI Patient Advocate Steering Committee (PASC) Meeting
OMB No.: 0925-0740
Expiration Date: 7/31/2022
Public reporting burden for this collection of information is estimated to average 2 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
(0925-0740). Do not return the completed form to this address.

Fill out the information below, then click Next to proceed. If you experience any difficulties when registering for the meeting, please contact Julia Poms julia.poms@nih.gov or Michelle
Watson: michelle.watson@nih.gov for assistance.

Personal Information
First Name:

Last Name:

Email Address:

Assistant Email:

Degree:

*Affiliation/Institute:

*Job Title:

*Department/Division:

https://www.cvent.com/Events/Register/InformationPage.aspx?rc=eb62ddd3-1f1a-43a1-a4b3-2bab3826fe55

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2/20/2020

NCI Patient Advocate Steering Committee (PASC) Meeting - Registration Information | Online Registration by Cvent

Contact Information
Work Address:
*Address:

*City:

State/Province:

*ZIP/Postal Code:

*Country:

*Work Phone:

Pursuant to the Americans with Disabilities Act, do you require specific
aids or services?

Will you be attending the March 26, 2020 dinner?
Yes
No

https://www.cvent.com/Events/Register/InformationPage.aspx?rc=eb62ddd3-1f1a-43a1-a4b3-2bab3826fe55

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2/20/2020

NCI Patient Advocate Steering Committee (PASC) Meeting - Registration Summary | Online Registration by Cvent

NCI Patient Advocate Steering Committee (PASC) Meeting
Your registration is almost complete. Please review your registration below and if everything is correct, click Next or Finish.

Registration Summary

Name

(Edit)

Email Address:
Assistant Email:

Degree:
Affiliation/Institute:

Job Title:
Department/
Division: CMRP

Work Phone:

Work Address:

Questions
REGISTRANT INFORMATION
Pursuant to the Americans with Disabilities Act, do you require specific aids or services?
Will you be attending the March 26, 2020 dinner?

https://www.cvent.com/Events/Register/GroupReg.aspx?rc=eb62ddd3-1f1a-43a1-a4b3-2bab3826fe55&ra=00000000-0000-0000-0000-000000000000

1

2/20/2020

NCI Patient Advocate Steering Committee (PASC) Meeting - Registration Summary | Online Registration by Cvent

https://www.cvent.com/Events/Register/GroupReg.aspx?rc=eb62ddd3-1f1a-43a1-a4b3-2bab3826fe55&ra=00000000-0000-0000-0000-000000000000

2