IPPCR Registration

Fall 2008 Introduction to the Principles and Practices of Clinical Research

October 27, 2008 - March 17, 2009

NOTE: On-line registration is only open to those individuals who plan to participate in the course on the NIH campus located in Bethesda, MD.

IPPCR Registration Form

Complete the form below and click the Continue button.
Items in *RED are required for processing your enrollment.
In order to receive certification for completing this course, you will need a unique student identification number. Your last name and a four digit number of your choosing will be used to create your ID and will ensure accurate tracking of your progress. It is suggested that you choose a 4 digit number that has some meaning for you and that you can easily remember.

Student Information

Check the following box if you are participating in this course on the NIH campus in Bethesda, MD.

*I will attend on the NIH campus:

Title:
*Last Name:
*First Name:
Middle Initial:
*4 Digit Code (Any 4-digit code that you can easily remember):
NIH Badge Number:
*Degree:
If your PRIMARY degree is not listed above, enter it here:
*Profession:
If your profession is not listed above, please enter it here:

Contact Information *Email Address (required to receive conformation of enrollment):

*(Area Code) Telephone # (555)555-5555:

(Area Code) Fax # (555)555-5555:

(Area Code) Pager # (555)555-5555:

Affiliation *NIH Employee:

Yes No

*NIH Institute/Center (IC):

If your IC is not listed above or you are not affiliated with the NIH, enter the name of your organization:
Lab/Branch/Department:
*NIH Building (or Street Address 1):
*NIH Room (or Street Address 2):
Mail Stop Code (4 digits):
*City (please change if incorrect):
*State:
*Zipcode (please change if incorrect):

The collection, maintenance and use of the personal information you submit via this website is protected under provisions of the Privacy Act of 1974. As such, all personally identifiable information you provide shall be treated as confidential, shall be used only for the purposes for which it was intended and shall be protected from unauthorized disclosure to the full extent permitted by the Act.

Please direct administrative questions about the course to: od_ippcr@mail.cc.nih.gov.
If you experience technical problems completing this form, please fill out our Technical Support Form or contact the webmaster at support@nihtraining.com or call 1.301.797.2386 or 800.30.MEDIA.
For more information about the Clinical Center e-mail occc@mail.cc.nih.gov, or call Clinical Center Communications, 301-496-2563.
Clinical Center National Institutes of Health Bethesda, Maryland 20892-7511