dESIgn Participant Registration Form

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* 1. Name

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* 2. Email

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* 3. School/Division

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* 4. Topic of research plan

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* 5. Mentor Name (if identified)

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* 6. If mentor not yet identified, do you need assistance identifying someone?

Yes

No

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* 7. Where are you currently in the process of developing your research plan?

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* 8. Do you have a funder (specific NIH institute or non-federal) and/or grant mechanism in mind?

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* 9. Preferred meeting location

In-person

Virtual

Hybrid

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* 10. My proposal is a:

New Submission

Resubmission

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* 11. Goal submission date

Date / Time

Date