Family/Last Name:
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Given/First Name
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Are you a current faculty member at the University of Kansas?
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Email Address
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Please provide your preferred credentials for this global health research/educational exchange forum. Examples include academic degrees such as M.D., Ph.D., MPH, M.Sc., etc. in addition to health care licensing credentials such as PT, OTR/L, CRNA, etc.
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Professional Title
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Name of Organization, Institution, or University
Department
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State
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Country
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Bio: Please provide your bio highlighting specific global health and international exchange interests and activity. If you have an online bio at your institution or another online source (such as LinkedIn) please also include the link(s) here.
Funded Global Health Research: Please list any global health research or funded research with international partners.
Unfunded Global Health Research: Please list any unfunded global health research or research collaborations with international partners.
Other Funded Research: Please list any research that may not be specific to global health, but may have future potential or possible links to global health initiatives.
Please provide five (5) keywords that most closely align with your areas of research interest. This will allow broad categories to feature specific faculty on the website.
Key Publications: Please list any publications related specifically to global health research or international educational exchange activities.
Global Health and International Educational Exchange Activities: Please list and describe any programs, collaborations, projects, training, patient care, and/or educational exchange activities in which you engage or may wish to engage.
Please provide five (5) keywords that most closely align with your areas of education interest. This will allow broad categories to feature specific faculty on the website as a group.
Future Global Health and International Educational Exchange Activities: Please list any upcoming or future projects. These can be aspirational goals or areas of interest not yet explored.
Please provide five (5) geographical locations in which you have previously or are currently engaged in education or research activities. The new website will feature a map of the group's reach across the world.
What are five (5) geographical locations in which you WISH TO engage in education or research?
Please upload your curriculum vitae.
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Please upload a current professional portrait of yourself.
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If I am selected to participate as a presenter or discussion moderator in an event, I give permission to the University of Kansas (the "University") and the University of Kansas Medical Center to use the information provided in this REDCap survey, including my photo and information included in my bio, for purposes of marketing and promoting this project.
I understand and agree that these marketing and promotional efforts may include, but are not limited to, videos, media articles, newsletters, brochures, websites, University communications, and annual reports published to information resources managed by the University as well as printed materials and posts on social media platforms, such as Facebook, Twitter, and Instagram, managed by the University.
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No
Please sign here to confirm giving permission for the statement above.
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If I am selected to participate as a presenter or discussion moderator for an event, I consent to having the event recorded (audio and visual) by the University. While I reserve all copyrights for the event presentation and any video or audio thereof, I grant the University a non-exclusive, royalty-free right to edit, use, and reproduce the recording of the event for promotional and non-commercial purposes, including, but not limited to, inclusion on the websites of the University's Office of International Programs.
I understand that I am responsible for obtaining permission prior to using any materials in the event (including recorded audio or video, slides, evaluation instruments, etc.) copyrighted by any other individual or organization. I waive all rights and agree to indemnify and hold harmless the University of Kansas (including the University of Kansas Medical Center), its affiliates, the Kansas Board of Regents, and the State of Kansas, and their respective employees, agents, and members, and will neither sue nor bring any proceeding against them, for any claim, demand, cause of action, compensation, royalties, or damages based upon or relating to the University's use of any presentation content, consistent with the preceding permission and release.
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Please sign here to confirm giving permission of the statement above.
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KU Medical Center privacy practices on how personal information is collected, stored, and used is available at the following links:
I attest that the information provided in this questionnaire is true and correct. I have reviewed and understand KU Medical Center privacy practices.
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