Form 1 Registration

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.

1. Enter email address to verify and create a new Office of Clinical Research Education and Collaboration Outreach (OCRECO) Account: _________________________________________________________________

2. Create a New Username and Password to complete the set-up of the OCRECO Learning Portal account and register for a course.

   1. Username:

   2. Password:

3. Complete the below information:

   1. First Name:

   2. Last name:

   3. Optional: Highest Degree Earned:

   4. Are you taking this course for academic credit or as part of an education/training/certification program?

      1. Yes

         1. Optional: If yes, please provide the name of your program: ______________________________________________

      2. No

   5. What is your current academic/professional status:

      1. Undergraduate student

      2. Medical student

      3. Pharmacy student

      4. Nursing student

      5. Dental student

      6. Veterinary student

      7. Graduate (other) student

      8. Resident/Fellow

      9. Post-doctoral/early career professional

      10. Established professional

      11. None of these

   6. Country:

      1. If U.S., state/territory:

4. Optional: Do you have an ORCID iD?

   1. Yes

      1. Optional: If you would be willing to provide your ORCID iD, please list it here: _____________________________________

   2. No

5. Pick the option that best describes you:

   1. I am an NIH employee, trainee, contractor, or special volunteer.

      1. 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

2. 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.

   1. My current affiliation is:

      1. Academia

      2. Industry

      3. Government

      4. Private Practice

      5. Hospital

      6. Clinical Research Organization

      7. Other

   2. Name of institution/company/organization:

   3. 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.)

      1. Yes

      2. No

3. I am not affiliated with any institution/company/organization.

1. How did you hear about this course? Choose one.

   1. NIH

   2. Institution/company/organization

   3. Internet search

   4. Friend/colleague