First Name
* must provide value
Last Name
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Email
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Department
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Anesthesia, Critical Care Medicine Dentistry Dermatology Emergency Medicine Medicine Molecular Biology Neurology Nursing Obstetrics and Gynecology Ophthalmology Orthopedics Pathology Physical Medicine and Rehabilitation Pediatrics Psychiatry Radiation Oncology Radiology Social Service Surgery Urology Other
Other Department
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Administrative contact/coordinator
Project, Program or Collaboration Name/Title (1)
* must provide value
Are you the Principal Investigator, Program Director or Lead Faculty?
* must provide value
yes
no
Please list the Principal Investigator/Program Director/Lead Faculty
* must provide value
Email of project lead
* must provide value
Project Description
* must provide value
Project Focus (select all that apply)
* must provide value
Patient Care Program
Health Professional Training/Medical Education
Research
Medical Innovation
Other
Other
* must provide value
Other participating MGH employees
Do you have additional projects/programs you would like to add?
* must provide value
Yes
No
Project, Program or Collaboration Name/Title (2)
* must provide value
Are you the Principal Investigator, Program Director or Lead Faculty?
* must provide value
yes
no
Please list the Principal Investigator/Program Director/Lead Faculty
* must provide value
Email of project lead
* must provide value
Project Description
* must provide value
Project Focus (select all that apply)
* must provide value
Patient Care Program
Health Professional Training/Medical Education
Research
Medical Innovation
Other
Other
* must provide value
Other participating MGH employees
Do you have additional projects/programs you would like to add?
* must provide value
Yes
No
Project, Program or Collaboration Name/Title (3)
* must provide value
Are you the Principal Investigator, Program Director or Lead Faculty?
* must provide value
yes
no
Please list the Principal Investigator/Program Director/Lead Faculty
* must provide value
Email of project lead
* must provide value
Project Description
* must provide value
Project Focus (select all that apply)
* must provide value
Patient Care Program
Health Professional Training/Medical Education
Research
Medical Innovation
Other
Other
* must provide value
Other participating MGH employees
Do you have additional projects/programs you would like to add?
* must provide value
Yes
No
Project, Program or Collaboration Name/Title (4)
* must provide value
Are you the Principal Investigator, Program Director or Lead Faculty?
* must provide value
yes
no
Please list the Principal Investigator/Program Director/Lead Faculty
* must provide value
Email of project lead
* must provide value
Project Description
* must provide value
Project Focus (select all that apply)
* must provide value
Patient Care Program
Health Professional Training/Medical Education
Research
Medical Innovation
Other
Other
* must provide value
Other participating MGH employees
Do you have additional projects/programs you would like to add?
* must provide value
Yes
No
Project, Program or Collaboration Name/Title (5)
* must provide value
Are you the Principal Investigator, Program Director or Lead Faculty?
* must provide value
yes
no
Please list the Principal Investigator/Program Director/Lead Faculty
* must provide value
Email of project lead
* must provide value
Project Description
* must provide value
Project Focus (select all that apply)
* must provide value
Patient Care Program
Health Professional Training/Medical Education
Research
Medical Innovation
Other
Other
* must provide value
Other participating MGH employees
Please list the countries your project/program(s) collaborate with
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Please list your project/program(s) primary partner organization(s)
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Which disease/condition keywords best describe your projects? (select all that apply)
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Accidents
Anesthesia/Pain
Antiretrovirals
Cancer
Cholera
Chronic Disease
Critical Care
Diabetes
Diarrhea
Disability
Disaster
Emergency
Heart Disease
HIV/AIDS
Infections
Injuries
Malaria
Medicine
Mental Health
Neurology
Neglected tropical diseases
Nursing
Nutrition
Opioids/SUD
Orthopedics
Palliative Care
Pathology
Prevention
Primary Care
Radiology
Reproductive
Surgery
Tuberculosis
Water/Sanitation
Women's Health
Vaccines
Other
Other
* must provide value
Which other project keywords best describe your programs? (select all that apply)
* must provide value
Access
Adolescents/Children
Affordability
Capacity
Community
Cost Effective
Delivery
Diplomacy
Epidemiology
Financing
Health IT
Health System
Human Rights
Innovation
LGBT
Maternal Health
Newborn/Infant Health
Policy
Public Health
Quality
Seniors/Ageing
Stigma
Other
Other
* must provide value
Which challenges do you face in supporting your work? (select all that apply)
Research administration
Program development
Fundraising
Subject-matter expertise
Publicity
Access to international partnerships
Access to collaborative work space
Other
Other
* must provide value
Can we contact you for additional information?
* must provide value
Yes
No