RAN Requestor Post Activity Reporting Form
Please complete the following information so we can learn more from your event/activity with the Researcher Ambassador(s).
Requestor's Name
*
First Name
Last Name
Email address
*
Consortium Role
*
Please Select
NCPE
CPGI
HPO
DRC
NIH program staff
Other
If you chose other, please specify your role
Organization/Institution
*
Researcher Ambassador's Name
*
First Name
Last Name
Do you have more than one Researcher Ambassador?
*
Yes
No
Please list the first and last names of any additional Researcher Ambassadors
Activity Information
Activity Title
*
Date of Activity
*
-
Month
-
Day
Year
Date
Location of Activity
*
Please Select
In Person
Hybrid
Virtual
If in person or hybrid activity is selected, please specify city and state.
Activity Description
*
Activity Purpose
*
Education/Awareness
Increase Workbench Users
Encourage DURAs
Activity Type
*
Please Select
Webinar
Lunch & Learn
Community Event
Formal Speaker Engagement/Presentation
Interactive Workshop
Testimonial
Booth/Tabling
Conference Panel
Digital Collateral Distribution
Email
Facebook Live
Newsletter
Social Media
Other
If selected other, please specify the type
Researcher Audience
*
Colleagues at your institution
Colleague at other institutions
Undergraduate Students
Graduate/ Professional Students
Clinical Students
Healthcare Providers
Post Doc Professionals
Allied Health Professionals
Early Career Tenure Track Researchers
Mid Career Tenured Researchers
Clinical Researchers
Researcher Project Personnel
UBR Audience
African American
American Indian or Alaska Native
Asian American
Latino/Hispanic
Middle Eastern and North African
Native Hawaiian or Other Pacific Islander
People Living with Disabilities
Rural
Sexual and Gender Minorities
Women
Researcher Engagement Framework
Which Categories Best Suit Your Event?
*
Outreach and Awareness
Education and Training
Capacity Building
Bridging Communities
Knowledge Mobilization
Activity Report Out
How many people attended?
*
If not applicable, please put N/A
If event was virtual, please state the engagement metrics
*
If not applicable, please put N/A
Key take-aways or lessons learned
*
Common questions or concerns
*
How many people wanted additional information on the program? How did you provide this information?
*
How many people took action or plan to take action to sign up for the workbench?
*
How many people requested an Institutional DURA?
*
What institutions were represented at the event?
*
Which institutions were interested in pursuing a DURA?
*
Please upload any images from the event
*
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Any follow-up steps recommended for the program?
*
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