Have you moved or changed jobs? You can let us know by completing this form. If you have any questions, please contact us at rwjcsp_admin@med.unc.edu or by calling (919) 843-1351.
Full Name
First
MI
Last
Degree 1
Degree 2 (Optional)
Degree 3 (Optional)
Former Program Site: Case Western University Columbia University Duke University George Washington University Johns Hopkins University McGill University University of California - Los Angeles University of California - San Francisco University of California - Stanford University of Chicago University of Michigan University of North Carolina University of Pennsylvania University of Washington Yale University Former VA Fellow? Yes No Institute of Medicine Member? Yes No Would you be willing to be an Alumni Ambassador ? Yes No
Home Mailing Address
Address Line 1
Address Line 2
City
State / Region
Country
Zip / Postal Code
Phone
Fax
Business Address (Domestic)
Institution Name
Business Phone
Business Fax
Preferred Email Address
Email Address
Position Title
Current Title 1
Current Title 2
Current Title 3
Clinical Information
Current Position / Title
Clinical Specialty
Clinical Subspecialty
Professional Discipline
Check all that apply: Academic Institution Professional
Institution Type - Medical School Public Health School Other
Rank (e.g. associate professor)
Biomedical Researcher/Health Care Researcher
Clinical Epidemiology Community-based Participatory Research Health Care Policy Health Services Research Social Sciences Research
Entrepreneur/Business Professional Government Official (Elected or Unelected) Nonprofit Administrator/Grantmaker
Other Professional Discipline
If Other, please specify:
Recent Accomplishments/Activities (In the last year)
Publications: Awards or honors: Grants: Other activities in which you may have “made a difference” in health care in your institution or community: Other comments you would like to share with us:
Veterans Administration Affiliation Information
Veterans Administration Appointment: Location: Roles and Responsibilities: Research Activities Underway:
Areas of Expertise/Topics of Study
Check all that apply: Addiction & Abuse
Alcohol Drugs Tobacco
Behavioral Health
Addiction Treatment Nutrition & Diet Mental Illness & Mental Health Physical Activity Prevention
Communications/Media
Advocacy Health Education & Health Promotion
Conditions & Diseases
Chronic Illness HIV/AIDS Obesity
Consumer/Patient Concerns Education
K-12 Education/Schools Medical Education
Healthcare Systems
Health Care Administration Health Care Financing Insurance/Coverage Managed Care Medicare/Medicaid/SCHIP Health Care Markets Safety Nets
Information Technology
Informatics Internet/E-Health Medical Technology
Medical Care & Services
Access to Care Clinical Care Dental/Oral Health End-of-Life Care/Palliative Care Long-Term Care Maternal/Child Health Care Nursing Pharmacy/Pharmaceuticals Primary Care Quality of Care Racial/Ethnic Disparities
Public Health
Environment/Environmental Health Community Health International Health Rural Health Urban Health
Public Policy
Community Design Health Policy Juvenile Justice Welfare Reform
Social Services
Community Development Faith-Based Interventions Housing Home-Based Services Parenting Youth Development
Violence
Child Abuse Community Violence Domestic Violence Elder Abuse Terrorism/Bioterrorism
Workforce Issues
Cultural Competence Recruitment Volunteering
Other Areas of Expertise
Characteristics of Targeted or Researched Populations
At-Risk/Vulnerable/Underserved Populations Children Persons with Disabilities Homeless Immigrants/Refugees Lesbians/Gays/Bisexuals/Transgenders Poor, Economically Disadvantaged Racial/Ethnic Minorities Women Other
Age of Targeted or Researched Populations
Infants/Toddlers Children Youth/Adolescents Young Adults Adults Aging/Elderly
Other information About You:
Career Stage
Select: Resident/Fellow New Professional Mid-Level Professional Seasoned Professional Retired Professional
Race (optional)
African American
Asian
Native Alaskan
Native American
Pacific Islander Puerto Rican
