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• Personal Contact Information

• Name Dr. Mr. Ms. Mrs. Salutation First Name Middle Name Last Name
• Title
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• City Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Not applicable Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming State/Province
• Current Institution Postal Code/Zip
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• Department Ext.
• Fax ###-###-####
• Country
• Phone Int Prefix +XX(X)
• Gender Male Female Primary Investigator Only

• Baccalaureate Degree

  Year of Degree
• Institution
• Degree Aa AAS AB AS BA BChir BE BM BS BS(EE) BSc BSN BSPH BTech ChB CM No Degree Other SB ScB

• Post-Baccalaureate Degree #1

  Year of Degree
• Institution
• Degree DCS DDM DDS DMD DMed DMn DMSc DNSc DO DPhil Drhabil DrPH DSc DSW DVM EdD Esq FAACB FRACP FRCP FRCPA FRCPC JD MA MB MBA MBBCh MBBS MBChB MD MD/PhD MDMS MEd MPA MPH MPhil MRCP MS MS/MA MSc MSN MSPH MSSA MSW No advanced degree PA PharmD PhD PhD/ScD PhyD PT RD RN ScD VDM VMD -

• Post-Baccalaureate Degree #2 (if applicable)

  Year of Degree
• Institution
• Degree DCS DDM DDS DMD DMed DMn DMSc DNSc DO DPhil Drhabil DrPH DSc DSW DVM EdD Esq FAACB FRACP FRCP FRCPA FRCPC JD MA MB MBA MBBCh MBBS MBChB MD MD/PhD MDMS MEd MPA MPH MPhil MRCP MS MS/MA MSc MSN MSPH MSSA MSW No advanced degree PA PharmD PhD PhD/ScD PhyD PT RD RN ScD VDM VMD -

• Post-Baccalaureate Degree #3 (if applicable)

  Year of Degree
• Institution
• Degree DCS DDM DDS DMD DMed DMn DMSc DNSc DO DPhil Drhabil DrPH DSc DSW DVM EdD Esq FAACB FRACP FRCP FRCPA FRCPC JD MA MB MBA MBBCh MBBS MBChB MD MD/PhD MDMS MEd MPA MPH MPhil MRCP MS MS/MA MSc MSN MSPH MSSA MSW No advanced degree PA PharmD PhD PhD/ScD PhyD PT RD RN ScD VDM VMD -

• Training

  Field of Research Training None Selected Anthropology Applied Mathematics Biochemistry Bioengineering Bioinformatics Biology Biophysics Botany Cell Biology & Regulation Chemistry Computational Biology Developmental Biology Economics Engineering Epidemiology Evolutionary Biology/Systematics Genetics Genomics Health Behavior Health Policy Health Services Research Imaging Science Immunology Material Science Mathematics Microbiology Molecular Genetics Nanotechnology Neuroscience Nursing Outcomes Research Parasitology Pathology Pharmacology Physics Physiology Population Biology/Ecology Psychology Reproductive Science Social Work Sociology Statistics Structural Biology Toxicology Other
• Field of Clinical Training ADL - Adolescent Medicine ADP - Addition Psychiatry AH - Developmental-behavioral Pediatrics AI - Allergy and Immunology ALI - Clinical and Laboratory Immunology AN - Anesthesiology APM - Pain Medicine AR - Abdominal Radiology BBK - Blood banking/transfusion Medicine CCA - Critical Care Medicine CCM - Critical Care Medicine CCP - Pediatric Critical Care Medicine CCS - Surgical Critical Care CD - Cardiovascular Disease CFS - Craniofacial Surgery CHN - Child Neurology CHP - Child and Adolescent Psychiatry CN - Clinical Neurophysiology CRS - Colon and Rectal Surgery CTR - Cardiothoracic Radiology D - Dermatology DMP - Dermatopathology DR - Radiology-Diagnostic EM - Emergency Medicine END - Endocrinology Diabetes & Metabolism ESM - Sports Medicine ESN - Endovascular Surgical Neuroradiology ETX - Medical Toxicology FM - Family Medicine FOP - Forensic Pathology FPG - Geriatric Medicine FSM - Sports Medicine GE - Gastroenterology GPM - Preventive Medicine GS - Surgery-General HEM - Hematology HMP - Hematology HO - Hematology and Oncology HSO - Hand Surgery HSP - Hand Surgery HSS - Hand Surgery IC - Interventional Cardiology ICE - Clinical Cardiac Electrophysiology ID - Infectious Disease IM - Internal Medicine IMG - Geriatric Medicine ISM – Sports Medicine ISM – Sports Medicine MG - Medical Genetics MGP - Molecular Genetic Pathology MM - Medical Microbiology MSR - Musculoskeletal Radiology N - Neurology ND - Neurodevelopment Disabilities NEP - Nephrology NNM - Neuromuscular Medicine NO - Neurotology None Selected NP - Neuropathology NPM - Neonatal-Perinatial Medicine NR - Nuclear Radiology NS - Neurological Surgery OAR - Adult Reconstructive Orthopaedics OBG - Obstetrics and Gynecology OFO - Foot and Ankle Orthopaedics OMO - Musculoskeletal Oncology ON - Oncology OP - Pediatric Orthopaedics OPH - Ophthalmology ORS - Orthopaedic Surgery OSM - Orthopaedic Sports Medicine OSS - Orthopaedic Surgery of the Spine OTO - Otolaryngology OTR - Orthopaedic Trauma P - Psychiatry PAN - Pediatric Anesthesiology PCC - Pulmonary Disease & Critical Care Medicine PCH - Chemical Pathology PCP - Cytopathology PD - Pediatrics PDC - Pediatrics Cardiology PDE - Pediatrics Endocrinology PDI - Pediatrics Infectious Disease PDO - Pediatrics Otolaryngology PDP - Pediatrics Pulmonlogy PDR - Pediatrics Radiology PDS - Pediatrics Surgery PE - Pediatrics Emergency Medicine PFP – Forensic Psychiatry PG - Pediatrics Gastroenterology PHO - Pediatrics Hematology/Oncology PM – Physical Medicine & Rehabilitation PMD – Pulmonary Disease PMN – Pain Medicine PN - Pediatrics Nephrology PP - Pediatrics Pathology PPM – Pain Medicine PPR - Pediatrics Rheumatology PRD - Pediatrics Dermatology PRM - Pediatrics Rehabilitation PS - Plastic Surgery PSM – Pediatrics Sports Medicine PTH – Pathology – Anatomic & Clinical PTX – Medical Toxicology PYG – Geriatric Psychiatry PYM – Psychosomatic Medicine RHM – Rheumatology RNR – Neuroradiology RO – Radiation Oncology SCI – Spinal Cord Injury Medicine SLM – Sleep Medicine SP – Selective Pathology TS – Thoracic Surgery U – Urology UM – Undersea and Hyperbaric Medicine UME – Undersea and Hyperbaric Medicine UP – Pediatrics Urology VIR – Vascular & Interventional Radiology VN – Vascular Neurology VS – Vascular Surgery

• Race/Ethnicity

  Primary Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Not Provided

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• Organization Information

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• Organization Type Non-Profit Organization Academic Institution For-Profit Company Hospital/Clinic
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• City Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Not applicable Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming State/Province Postal Code/Zip
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