HFRCC Interest Form Question Title * 1. What is your first name? Question Title * 2. What is your last name? Question Title * 3. Title: Question Title * 4. Organization Type: Academic Institution State, Local, or Federal Government Agency Non-Profit Non-Governmental Agency Company or Consultant Other (please specify) Question Title * 5. Research Area:Major Area of Expertise (Please select all that apply) Advocacy Service Basic Science Clinical Practice Public Health Education Other (please specify) Question Title * 6. Research Interests: Question Title * 7. How did you learn about the HFRCC? Current Member Media Conference or Event Community-Based Organization Other (please specify) Question Title * 8. What services can the HFRCC provide that would help support the work you do? Opportunities to form new partnerships Capacity building (e.g. research training) Professional development Information about funding opportunities Mentorship Other (please specify) Question Title * 9. Address Organization Address Address 2 City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Code Email Address Phone Number Question Title * 10. Would you like to receive additional information about the HFRCC? Yes No Question Title * 11. Would you like to be included in an online HFRCC directory? Yes No Done
