Home
Membership
Login
News
Employment
Marshfield
CTSA Web
Contact
UW ICTR
About
Client Services Center
Directors
Newsletter
Education & Training
Career Development
Education
Biostatistics & Informatics
Biostatistics
Informatics
Community Research
About
Research Resources
Research Projects
Education
Outreach
Investigator Resources
Health Equity Ctr
Core Laboratories
CRIS
CTRC (GCRC)
Research Funding
WiNHR
Home
Membership Form
Fields marked with an asterisk are required.
Membership
Member Type :
*
Investigator (includes community-based)
Affiliate
Student/Trainee
Community Member
Research Staff (includes community-based)
Click here to learn about membership types
Name
First Name:
*
Middle Name:
Last Name:
*
Business Address
Institution/Organization:
*
University of Wisconsin Madison
Marshfield Clinic
Other
If other, specify :
Address Line 1 :
*
Address Line 2:
City :
*
State:
*
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan(MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
County:
*
Country:
The United States of America (USA)
Algeria
Argentina
Armenia
Australia
Austria
Azerbaidzhan
Belgium
Bosnia-Herzegovina
Brasil
Great Britain
Bulgaria
Byelorussia
Canada
Chile
China
Colombia
Croatia (Hrvatska)
Cyprus
The Czech Republic
Denmark
Egypt
Finland
France
General
Georgie
Germany
Greece
Hungary
Iceland
India
Indonesia
Iran
Ireland
Israel
Italy
Japan
Jordan
Kazachstan
Luxemburg
Malaisia
Malta
Mexico
Nepal
The Netherlands
New Zealand
North Korea
Norway
Peru
Philippines
Poland
Portugal
Romania
Russia
Scotland
Singapore
Slovenia
South Africa
South Korea
Spain
Sweden
Switserland
Taiwan
Thailand
Tunesia
Turkey
The Ukraine
Uzbekistan
Venezuela
Zip/Postal Code:
*
Business Contact Information
Primary Telephone:
*
Other Telephone:
Fax :
Email :
*
Retype Email:
*
Professional Information
Professional Title:
*
Click here for examples of professional title
School/College/Business:
*
Department:
Section/Division/Unit:
Group Affiliation 1:
*
None
AHEC
CAP
CCHE
CHC
CTRC
CTRI
CWHR
GLITC
GRECC
HIP
ICTR
La Follette School
Marshfield PMP
MESA
MIRR
Primate Center
SEIPS
SHOW
Sonderegger Center
UWCCC
UWCDH
UWPHI
Waisman Center
WiNHR
WON
WREN
Other
Group Affiliation 2:
None
AHEC
CAP
CCHE
CHC
CTRC
CTRI
CWHR
GLITC
GRECC
HIP
ICTR
La Follette School
Marshfield PMP
MESA
MIRR
Primate Center
SEIPS
SHOW
Sonderegger Center
UWCCC
UWCDH
UWPHI
Waisman Center
WiNHR
WON
WREN
Other
Academic Degrees Completed
Degree 1:
*
None
BA
BS
BSN
DDS
DNSc
DO
DrPH
DVM
EdD
MA
MBA
MD
MLIS
MPH
MS
MSE
MSN
MSW
NP
PA
PharmD
PhD
ScD
Other
Degree 2:
None
BA
BS
BSN
DDS
DNSc
DO
DrPH
DVM
EdD
MA
MBA
MD
MLIS
MPH
MS
MSE
MSN
MSW
NP
PA
PharmD
PhD
ScD
Other
Degree 3:
None
BA
BS
BSN
DDS
DNSc
DO
DrPH
DVM
EdD
MA
MBA
MD
MLIS
MPH
MS
MSE
MSN
MSW
NP
PA
PharmD
PhD
ScD
Other
If other, specify:
Demographic Information
Are you Hispanic, Latino or Spanish?:
Yes
No
Click here to view definitions of ethnicity and race
Race:
Prefer not to answer
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Asian
Black or African-American
White
More than one race
Gender:
Male
Female
Age:
In which of the following languages are you fluent ?
Click here to expand and select languages
Arabic
Bengali
Chinese
Czech
Danish
Dutch
English
French
German
Greek
Hebrew
Hindi
Hungarian
Icelandic
Italian
Japanese
Norwegian
Polish
Portuguese
Romanian
Russian
Spanish
Swedish
Other
Research
1. a. Research type (Check all active research types)
Click here to view definitions of research types
Basic
Type I Translational
Patient oriented(Clinical)
Educational
Public/Population Health
Type II Translational
If yes, patient type involves:
Human Subjects
Animal
b.If you have checked more than one for 1(a), indicate primary research type:
Basic
Type I Translational
Patient oriented(Clinical)
Educational
Public/Population Health
Type II Translational
c. If you have an NIH "eRA Commons" username, please list it here :
2. In your research, do you focus on a particular research population(s) ? (if no, skip to question no.3):
(Select One)
Yes
No
a. Targeted human age: (Select all that apply)
Neonates
Infants
Toddlers/Preschool
Elementary School
Middle School
High School
Adults (18 - 65)
Geriatrics (> 65)
N/A
Targeted animal type and age: (Select all that apply):
Large
Small
Both
N/A
Animal Neonates
Animal Embryonic
Animal Immature
Animal Adult
b. Targeted gender (please answer for humans and animals):
Female
Male
N/A
c. Targeted ethnic or racial group:
Click here to expand and select ethnic or racial group
Hispanic or Latino
American Indians or Alaskan Native
Native Hawaiian or other Pacific Islander
Asian
Black or African-American
White
N/A
d. Disabled population/special health care needs:
Yes
No
If yes, please describe:
e. Underserved population:
Yes
No
Click here for definition of underserved population
If yes, please describe:
f. AIDS/HIV affected population :
Yes
No
3. a. Is your research multidisciplinary in nature ?:
Yes
No
Click here for definition of multidisciplinary research
If Yes, how much of your research is multidisciplinary:
Some
Most
All or Nearly All
b. What is your research discipline ? :
Biochemistry
Biophysics
Biostatistics/Statistics
Biotechnology
Chemistry
Computer Science
Dentistry
Engineering
Environment Sciences
Epidemiology
Ethics
Genetics
Health Administration
Health Economics
Health Education
Health Policy
Health Services
Immunology
International Health
Law
Library Science
Medicine
Medical Informatics
Medical Physics
Medicinal Chemistry
Molecular/Cellular Biology
Neuroscience
Nursing
Nutritional Sciences
Occupational Therapy
Pathology
Pharmacology
Pharmacy
Physical Therapy
Physiology
Psychology
Public Health
Radiology
Respiratory Therapy
Social Sciences
Social Work
Speech Pathology
Veterinary Medicine
Other
If other, specify :
c. With what other discipline(s) do you collaborate ? (Select by expanding the following link) :
Click here to expand and select collaborating discipline(s)
Biochemistry
Biophysics
Biostatistics/Statistics
Biotechnology
Chemistry
Computer Science
Dentistry
Engineering
Environment Sciences
Epidemiology
Ethics
Genetics
Health Administration
Health Economics
Health Education
Health Policy
Health Services
Immunology
International Health
Law
Library Science
Medicine
Medical Informatics
Medical Physics
Medicinal Chemistry
Molecular/Cellular Biology
Neuroscience
Nursing
Nutritional Sciences
Occupational Therapy
Pathology
Pharmacology
Pharmacy
Physical Therapy
Physiology
Psychology
Public Health
Radiology
Respiratory Therapy
Social Sciences
Social Work
Speech Pathology
Veterinary Medicine
Other
4. Is your research ?:
Observational or Descriptive
Interventional
Both
Neither
5. If your research is interventional:
a. Please select one :
Diagnostic
Preventive
Therapeutic
Palliative
N/A
b. Choose the research setting in which it occurs by expanding the following link:
Click here to expand and select intervention setting
Ambulatory care setting
Community-based organization
Correctional facility
Critical Care Setting
Daycare
Home/Residence
Inpatient setting (non-critical care)
Rehabilitation facility
School
Skilled nursing facility/nursing home
Supervised living facility
Urgent care/ED setting
Workplace
Other
If other, specify :
c. Choose the research categories by expanding the following link
Click here to expand and select research category
Behavioral Modification
Biologic (including vaccine)
Community Based Participatory Program
Complementary/Alternative Medicine
Computer Enhanced Learning
Delivery of Care/Care Coordination
Device
Dietary/Nutritional Supplement
Drug
Educational/Instructional/Informatics
Environmental Control
Exercise
Gene Therapy
Health Policy Change
Health Surveillance/Screening/Survey
Neuropsychological
Occupational Therapy
Organ Transplant
Patient Advocacy Program
Patient Navigation Program
Patient Safety Program
Personalized Medicine/Pharmacogenetics
Physical Therapy
Radiation
Rehabilitation
Speech Therapy
Stem-cell Treatment
Support Group
Surgical repair
Tomotherapy
N/A
Other
If other, specify :
6. If your research is observational or descriptive, please specify the appropriate research categories
Select observational or descriptive type
Adherence
Behavioral & Social
Decision Making
Complementary/Alternative Medicine
Evaluation
Health Economics/Pharmacoeconomics
Health Policy
Patient Safety
Other
N/A
If other, specify :
7. a. Research focus areas ((Select by expanding the following link)
Click here to expand and select research focus area
Anatomy[A]
Organisms[B]
Diseases[C]
Bacterial infections and mycoses[C01]
Virus Diseases[C02]
Neoplasms[C04]
Musculoskeletal diseases[C05]
Digestive system diseases [C06]
Stomatognathic diseases [C07]
Respiratory tract diseases [C08]
Otorhinolaryngologic diseases [C09]
Nervous system diseases [C10]
Eye diseases [C11]
Male urogenital diseases [C12]
Female urogenital diseases [C13.351]
Pregnancy complications [C13.703]
Cardiovascular diseases [C14]
Hematologic diseases [C15.378]
Lymphatic diseases [C15.604]
Congenital abnormalities [C16.131]
Fetal diseases [C16.300]
Genetic diseases, inborn [C16.320]
Infant, Newborn, diseases [C16.614]
Connective tissue diseases [C17.300]
Skin diseases [C17.800]
Metabolic diseases [C18.452]
Nutrition disorders [C18.654]
Endocrine system diseases [C19]
Immune system diseases [C20]
DNA damage [C21.111]
Environmental illness [C21.223]
Motion sickness [C21.335]
Occupational diseases [C21.447]
Poisoning [C21.613]
Preconception injuries [C21.676]
Substance-related disorders [C21.739]
Wounds and injuries [C21.866]
Animal diseases [C22]
Pathological conditions, signs and symptoms [C23]
Chemicals and Drugs [D]
Analytical, Diagnostic, and Therapeutic Techniques and Equipment [E]
Diagnosis [E01]
Therapeutics [E02]
Anesthesia and analgesia [E03]
Surgical procedures, operative [E04]
Investigative techniques [E05]
Dentistry [E06]
Equipment and supplies [E07]
Psychiatry and Psychology [F]
Behavior and behavior mechanisms [F01]
Psychological phenomena and processes [F02]
Mental disorders [F03]
Behavioral disciplines and activities [F04]
Biological sciences [G]
Biological sciences [G01]
Health Occupations [G02]
Environment and Public Health [G03]
Biological Phenomena, Cell Phenomena, and Immunity [G04]
Genetic Processes [G05]
Biochemical Phenomena, Metabolism, and Nutrition [G06]
Physiological Processes [G07]
Reproductive and Urinary Physiology [G08]
Circulatory and Respiratory Physiology [G09]
Digestive, Oral, and Skin Physiology [G10]
Musculoskeletal, Neural, and Ocular Physiology [G11]
Chemical and Pharmacologic Phenomena [G12]
Genetic Phenomena [G13]
Genetic Structures [G14]
Natural sciences [H]
Anthropology, Education, Sociology, and Social Phenomena [I]
Social sciences [I01]
Education [I02]
Human activities [I03]
Technology, Industry, Agriculture [J]
Food and Beverages [J02]
Humanities [K]
Information Science [L]
Named groups [M]
Health Care [N]
Population characteristics [N01]
Health care facilities, manpower, and services [N02]
Health care economics and organizations [N03]
Health services administration [N04]
Health care quality, access, and evaluation [N05]
Delivery of health care [N05.300]
Ethics [N05.350]
Health services research [N05.425]
Quality assurance, health care [N05.700]
Quality of health care [N05.715]
Publication characteristics [V]
Geographicals [Z]
If other, specify :
b.
To further describe the focus of your research, provide your Key Research Terms.
DO NOT JUST PUT WORDS
INTO THE BLANKS BELOW!
Copy and Paste terms from the MeSH database following the example for all 5 keywords. When terms are identified drag from right to left to highlight the term and then copy. To choose the
key research terms that match (but do not replicate) your 7a choices.
Click here to find keywords using MeSH guidelines
1:
Ex. Carbon Compounds, Inorganic [D01.200]
2:
3:
4:
5:
8.a. Do you have grant support for your research activities ?:
Yes
No
b. Please enter the following contact information for the person that handles your grants and biosketch
Full Name:
Email Address:
Phone Number:
c. If you want to attach your bioskech, You will be able to do so after submitting this form
Search Portal
User login
Username:
*
Password:
*
Request new password
