HFRCC Network Application – Healthy Flint Research Coordinating Center

* = required

General Information

First name*

Last Name*

Email Address*

Phone

Credentials

Please select your degree(s) (select all that apply).

Other credential(s):

Primary Organization Type

Academic Institution
Community-based organization
Company or Consultant
Local or Federal Government Agency
Non-Profit Non-Governmental Agency
None

Primary organization/Institution name

Title

What is your title at your primary organization?

Do you have other affiliations you'd like to include?

Yes

Other Organization Type

Academic Institution
Community-based organization
Company or Consultant
Local or Federal Government Agency
Non-Profit Non-Governmental Agency
None

Other organization/Institution name

Other Organization - Title

What is your title at your other organization?

Community Details

What is your role in your community-based organization?

Community health worker
Social WOrker
Director
Program/Case manager
Health Educator
Navigator
Other

Community Other

Academic Details

Hidden

Department - HIDDEN/not used

Department

What department do you work in at your academic institution? If you work in more than one department, feel free to include multiple in your response.

Role

What is your role at your academic institution?

Faculty member
Staff member
Student, post-doctoral fellow, or trainee

Additional Questions

Area(s) of Expertise

What is your area of expertise? Select up to 3.

Advocacy
Basic Science
Clinical Practice
Education
Other
Outreach/Engagement
Public Health
Service
Teaching

Other area(s) of expertise (if any)

Interests

What are your areas of interest (in research, service, teaching, etc.)?

Brief Biography

Please provide a brief biography

Website(s)

If you have a website(s) or social media you’d like to share, please include that information below (information about project specific websites can be shared through the Project Index).

Website 1 name

Website 1 URL

Website 2 name

Website 2 URL

Website 3 name

Website 3 URL

Additional Information

Are you interested in making new Flint connections?

Yes
No

Can we list your name, credentials, title, organizations, website(s), and areas of expertise and interest on our website?*

Yes
No
Include some information

Partial information

Please specify what contact information can be made public.

Can we include your contact information on our website?*

Yes
No
Include some or different from previously entered contact information

Partial contact information

Please specify what contact information or different contact information than previously entered can be shared.

How did you hear about the Healthy Flint Research Coordinating Center (HFRCC)?

(select all that apply)

Academic Partner
Community Partner
HFRCC website
HFRCC social media
HFRCC event (e.g., symposium, webinar, community dialogue, etc)
Professional group
Conference or event
Newsletter or email
Other

Please specify

What can the HFRCC do to help you succeed with your Flint related work?

Upload your Resumé, CV or biosketch

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Profile photo

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Any other comments you would like to share?

Name

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