Form 15 CIRB New Board Member Biographical Sketch Form

OMB#: 0925 – xxxx Expiry Date: xx/xx/xxxx
STATEMENT OF CONFIDENTIALITY:
Collection of this information is authorized under 42 USC 285a. While your participation is completely voluntary, to
participate in the NCI CIRB, completion of this form is required. Data collected as part of the NCI CIRB review is private
and protected by law. Under the provisions of Section 301d of the Public Health Service Act, no information that could
permit identification of a participating individual may be released. All such information will be kept private under the
Privacy Act and will be presented only in statistical or summary form.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN:
Public reporting burden for this collection of information is estimated to average 30 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-xxxx*). Do not return the completed form to this address.

Attachment 3B: Biographical Sketch Form
Name:
1. What college or university did you attend, if applicable?
2. When did you graduate and with what degree, if applicable?
3. What skills, knowledge and experience are you bringing to the Board?
4. What name, title and place of employment do would you like listed on
the NCI CIRB website for yourself?

New Board Member Orientation

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NCI CIRB Initiative