ACTRI Membership Application
Please Answer the Following Questions
Approved Membership Criteria
General Membership (Highest Level) = Answer YES to any one of the questions 1, 2, or 3. The status is Approved - General Associate Membership = If all questions are No for 1, 2, and 3 but answer YES to any one of questions 4, 5 or 6 = Associate Membership Affiliate Membership = If answers 1, 2, 3, 4, 5, and 6 all = NO, then Question 7. must select any option except for None.
1. Have you or do you currently serve as a PI or co-PI at UC San Diego or affiliated institutions on funded research?
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YES
NO
2. Do you have a track record of clinical and/or translational research at UC San Diego or an affiliated institution?
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YES
NO
3. Are you enrolled in a KL2, K12, K08 or K23 program at UC San Diego or affiliated institutions?
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YES
NO
4. Do you currently participate in the ACTRI CREST, or Translational Science Certificate programs?
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YES
NO
5. Do you currently participate in ACTRI activities (e.g., reviewing pilot project grants)?
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YES
NO
6. Have you or do you currently collaborate in research conducted by other ACTRI General Members?
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YES
NO
7. ACTRI Partner Institution or Organization
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University of California, San Diego
Eisenhower Health System
La Jolla Institute for Allergy & Immunology
Sanford Burnham Prebys Medical Discovery Institute
Rady Children's Hospital-San Diego
Mesa College
Salk Institute
VA San Diego Healthcare System
El Centro Regional Medical Center
San Diego Community College District
None
Other
Personal and Contact Information
*
Indicates Required Fields
Are you a UCSD PI or Co-PI?
*
YES
NO
Biosketch/CV Upload
Upload a File
Note: Biosketch files MUST be in PDF, Microsoft Word (.doc), or Word 2007 (.docx) format.
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of
Applicant (retired 5/19/22)
First Name
Middle Initial
Last Name
Full Name
First Name
*
Last Name
*
Applicant's Academics
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(PhD, MD, etc.)
Department
Division
Phone Number
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-
Area Code
Phone Number
Applicant E-mail Address
*
Demographic
Questions
What is your current gender identity? (Please select only one)
Female
Trans Female/Trans Woman
Male
Trans Male/Trans Man
Nonbinary
Different Identity
Decline to State
What is your age range?
0-17
18-24
25-34
35-44
45-54
55-64
65+
Do you consider yourself to be: (Please select only one)
Heterosexual or Straight
Gay or Lesbian
Bisexual
Not listed above
Decline to State
Are you Hispanic or Latino?
Mexican/Mexican American
Latin American/Latino
Other Spanish/Spanish American
No
Select one or more of the following racial categories that best describe you, if applicable.
AMERICAN INDIAN OR ALASKA NATIVE Description: A person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.
Chinese/Chinese American
Filipino/Filipino American/Pilipino/Pilipino American
Japanese/Japanese American
Korean/Korean American
Pakistani/Pakistani American/Indian/Indian American
Vietnamese/Vietnamese American
Other Asian/Asian American
BLACK OR AFRICAN AMERICAN Description: A person having origins in any of the Black racial groups of Africa.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER Description: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
European
Middle Eastern
North African
White (Not Specified)
Decline to state
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Submit
Membership Level
Update Membership Status
ALL 1-3 Questions = NO
ANY 4-6 Questions = YES
Should be Empty: