To attend this course, you must be a VA Employee or WOC. Please confirm your VA status:
Yes, I am a VA Employee or WOC

IRB Administrator status
OR
prerequisite fulfillment:

Yes, I have been an IRB Administrator for more than 2 years **
      OR
Yes, I have had HRPP 101, IRB 101 or PRIM&R training **

Dr/Ms/Mr:

Dr. Ms. Mr. **

First Name:  

Last Name:

Degree (M.D., Ph.D., etc.): 

How you want your name to appear on the conference name badge?

Position Title:

VISN Number:

VA Medical Center Name:

VA Station Number:

VA Routing Number:

City:

State:

Zip Code:

Phone Number
(123-456-7890):

Phone Extension
(12345):

Fax Number
(123-456-7890):

E-mail Address:

Special Physical or Meal Needs:

Secondary Contact if you can't be reached (Name and Phone):