Program Affilation Transaction Form
Required NIH Reporting Information for CFAR Program Users and Affiliates
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First Name (entire first name)
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Last Name
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Email Address:
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Institution Affiliation:
Harvard University
Beth Israel Deaconess Medical Center
Brigham and Women's Hospital
Dana Farber Cancer Institute
Immune Disease Institute
Lemuel Shattuck Hospital
Mass General Hospital
New England Primate Research Center
Other (please specify)
If Other, Please list Institution:
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Your Research Location(s) (City):
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What is your primary area of research?
Behavioral and Social Sciences
Clinical Epidemiology and Outcomes Research
Pathogenesis
Therapeutics
Vaccine
Retrovirology
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Does your work involve International Research?
Yes
No
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Investigator Level: Please select one
NIH Independent Investigator (AIDS R01 funding or higher)
NIH Independent Investigator (Non-AIDS R01 funding or higher)
NIH New Investigator (No R01 yet and within 10 years of final degree)
Faculty member with no history of (non-CFAR) NIH funding
Post doc or Research Fellow
Undergraduate or Graduate Student
Lab Staff or Community Member
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NIH Special Emphasis Category: Please select any that apply
Current recipients of Developmental Core awards, salary support, mentoring, and/ or other services
Current recipients of NIH Administrative Supplement funds
Member of an Underrepresented Group in Research (African Americans, Hispanics, American Indians, Alaska natives, native Hawaiians, Pacific Islanders)
Woman
None
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Are you affiliated in any way with other NIH Institutes and Centers?
None
FIC: Fogarty Int’l Center
NIA: Institute on Aging
NCI: Cancer Institute
NHLBI: Heart, Lung, Blood
NIAID: Allergy and Infectious Disease
NICHD: Child Health and Human Development
NIDA: Drug Abuse
NIMH: Mental Health
NCCAM: Complementary and Alternative Medicine
NIAAA: Alcohol Abuse and Alcoholism
NIDCR: Dental and Craniofacial Research
NIDDK: Diabetes and Digestive and Kidney Diseases
NINDS: Neurological Disorders and Strokes
NINR: Nursing Research
If yes to any of these please explain
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Please select the program in which you are reporting your involvement.
Behavioral and Social Sciences
Clinical Epidemiology and Outcomes
International
Pathogenesis
Therapeutics
Vaccine
Other
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Please provide a very brief description of the involvement or benefit received.
0/1000 characters
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If support received was for a project please provide the project title or indicate the support was not for a project.
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If support received was for an NIH project, please list the Grant #. If it was not an NIH project, please list the project sponsor or indicate the support was not for a project.
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Did the HU CFAR support received result or contribute in any way to a publication?
Yes, it supported a publication
Yes, the CFAR was acknowledged in the publication
No
If yes, please provide the publication title, journal name, and PMCID # if available.
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Indicates Response Required