Form 1 Registration

ALS Strategic Planning Workshop Registration Fields (2022)

NOTE: All questions are required except where noted as “(optional)”

OMB#: 0925-0740 Expiration date: 09/2025

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 (0925-0740). Do not return the completed form to this address.

1. Prefix (drop-down options) (optional)

   1. Dr.

   2. Prof.

   3. Ms.

   4. Mrs.

   5. Mr.

2. First Name (open entry)

3. Last Name (open entry)

4. Email Address, which must be used to join the workshop (open entry)

5. Job Title (open entry) (optional)

6. Institution/Primary Affiliation (open entry) (optional)

7. Website or social media link (open entry) (optional)

8. Do you identify as a person with lived experience of ALS (ex. diagnosis, pre-manifest carrier, caregiver…)?

   1. Yes

   2. No

   3. I don’t know

9. (conditional if “yes”) Please indicate how you identify as a person with lived experience of ALS (open entry) (optional)

10. Do you currently describe yourself as male, female, or transgender? (check all that apply)

    1. Female

    2. Male

    3. Transgender Female

    4. Transgender Male

    5. Another Gender Identity

    6. Prefer not to answer.

11. Which of these options best describes your ethnicity?

    1. Hispanic or Latino

    2. Not Hispanic or Latino

    3. Prefer not to answer

12. Which of these options best describes your race? (choose one or more)

    1. American Indian or Alaska Native

    2. Asian

    3. Black or African American

    4. Native Hawaiian or Other Pacific Islander

    5. White

    6. Prefer not to answer

13. If you require a reasonable accommodation to participate in the virtual meeting (e.g., sign language), please indicate below no later than October 17. (open entry) (optional)