Registration Form

Registration Form Instructions:

Complete the form below and click the Continue button.
Items in *BOLD 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 such as the last 4 digits of your Social Security Number or something similar.

Personal Information

Title:
*Last Name:
*First Name:
Middle Initial:
*4 Digit Number (Use a number familiar to you):
NIH Badge Number:
Month of Birth:
Day of Birth:
*Degree:
If your PRIMARY degree is not listed above, enter it here:
Profession:

Contact Information

*Email Address:
*Area Code & Telephone # or International Tel. #:

Affiliation

*Are you an employee at the NIH campus in Bethesda, MD?
*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:
*State:
*Zipcode:
Country:

Manufacturers assistance - Please direct all manufacturers assistance questions to MATT@CBER.FDA.GOV
Please direct administrative questions about the course to: CC-OD_fda@cc.nih.gov.
If you experience problems playing video, contact the Technical Assistance Support Center at ithelpdesk@nih.gov or 301-594-6248.
If you experience technical problems completing this form, please complete the 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 http://www.cc.nih.gov/comments.shtml, or call Clinical Center Communications, 301-496-2563.
Clinical Center National Institutes of Health Bethesda, Maryland 20892-7511

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.