Membership Form Thank you for your interest in a Third Coast Center for AIDS Research membership.
Please complete the form below to register as a Third Coast CFAR member. Third Coast CFAR Faculty Member - This membership is available to investigators at Northwestern University, University of Chicago, and Lurie Children's Hospital who are eligible to apply for NIH grants as a principal investigator
Affiliate Member - This membership available to anyone engaged in HIV research or services in the Chicagoland area
Supporting Member - This membership is available to anyone
Ms. Miss Mrs. Mr. Mx. Dr. Prof.
First or Preferred Name
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Last Name
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What is the highest level of education you have completed?
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Medical Degree (MD, MBBS, DO)
Doctoral Degree (PhD or other)
Dual MD/PhD or equivalent
Other Clinician (NP, PA, RN)
Master's Degree
Bachelor's Degree
Other
please choose one
You selected 'Other' for your highest level of education. What is your highest level of education?
Please specify your degree(s)
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e.g. MD, MBBS, PhD, MS, MA
Preferred Email Address
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Include Area Code
Preferred Gender Pronouns
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she/her/hers
he/him/his
they/them/theirs
not listed
Please indicate your preferred gender pronouns
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Affiliated Institution
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Northwestern University / Lurie Children's Hospital
University of Chicago
Howard Brown Health
Chicago Department of Public Health
Illinois Department of Public Health
Center on Halsted
AIDS Foundation of Chicago
AllianceChicago
Not listed
What institution are you affiliated with?
Department
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Primary Department
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Link to faculty/professional profile
Position
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Check all that apply
You selected 'Other' for your Position. What is your Position?
What are your research interests?
Check all that apply
You selected 'Other' for your research interests. What are your research interests?
Have you ever received funding from NIH?
Yes, including independent NIH funding for HIV research
Yes, including independent NIH funding for non-HIV research
Yes, including co-investigator or similar role on NIH-funded project (e.g. not the PI)
No, I have not received funding from NIH
Check one
Have you ever received independent funding from NIH as the PI of a grant?
Yes, including independent NIH funding for HIV research where I was the PI
Yes, including independent NIH funding for non-HIV research where I was the PI
No, I have not received independent funding from NIH
Check one
Please provide your NIH grant number(s) or NIH RePORTER link
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Please indicate the types of communication you would like to receive from the Third Coast CFAR
Check all that apply
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Please indicate the types of communication you would like to receive from the Third Coast CFAR
Check all that apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
More than One Race
Not Listed
I prefer not to answer
Hispanic or Latino
Not Hispanic or Latino
I prefer not to answer
Cisgender Woman
Cisgender Man
Transgender Woman/Transfeminine
Transgender Man/Transmasculine
Non-binary/Gender non-conforming/Genderqueer
Not Listed
I prefer not to answer
Are you a sexual or gender minority?
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Yes
No
I prefer not to answer
Yes
No
I prefer not to answer
Do you meet the definition of an individual from a disadvantaged background, as defined by NOT-20-031 ?
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Yes
No
I prefer not to answer