OMB # 0925-0764
Expiration Date: XX/XXXX
Office of Clinical Research Education and Collaboration Outreach (OCRECO) Learning Portal Participant Registration Form (Online)
Public reporting burden for this collection of information is estimated to average (5) 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 (0925-0764). Do not return the completed form to this address.
Enter email address to verify and create a new Office of Clinical Research Education and Collaboration Outreach (OCRECO) Account: _________________________________________________________________
Create a New Username and Password to complete the set-up of the OCRECO Learning Portal account and register for a course.
Username:
Password:
Complete the below information:
First Name:
Last name:
Optional: Highest Degree Earned:
Are you taking this course for academic credit or as part of an education/training/certification program?
Yes
Optional: If yes, please provide the name of your program: ______________________________________________
No
What is your current academic/professional status:
Undergraduate student
Medical student
Pharmacy student
Nursing student
Dental student
Veterinary student
Graduate (other) student
Resident/Fellow
Post-doctoral/early career professional
Established professional
None of these
Country:
If U.S., state/territory:
Optional: Do you have an ORCID iD?
Yes
Optional: If you would be willing to provide your ORCID iD, please list it here: _____________________________________
No
Pick the option that best describes you:
I am an NIH employee, trainee, contractor, or special volunteer.
Select your institute or center from the below options:
NCI
NEI
NHLBI
NHGRI
NIA
NIAAA
NIAID
NIAMS
NIBIB
NICHD
NIDCD
NIDCR
NIDDK
NIDA
NIEHS
NIGMS
NIMH
NIMHD
NINDS
NINR
NLM
CC
CIT
CSR
FIC
NCATS
NCCIH
OD
I am currently affiliated with an institution/company/organization. Affiliation refers to a current institution/company/organization that you may be a part of as the following: employee, student, faculty, or trainee. If you have multiple affiliations, please list the one that is most current and primary for you.
My current affiliation is:
Academia
Industry
Government
Private Practice
Hospital
Clinical Research Organization
Other
Name of institution/company/organization:
Would you like to be a Local Site Liaison for either the IPPCR or PCP course? (We suggest local site liaisons to do the following: assist in promotion and marketing of the course, share all course announcements from the NIH course coordinator and facilitate small group sessions to discuss course materials.)
Yes
No
I am not affiliated with any institution/company/organization.
How did you hear about this course? Choose one.
NIH
Institution/company/organization
Internet search
Friend/colleague
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | curriem |
File Modified | 0000-00-00 |
File Created | 2024-09-14 |