IHPBA Faculty Directory

IHPBA Faculty Directory
1. Are you a current IHPBA member*

YesNo

The IHPBA Faculty Directory is available to IHPBA members, for more information and to join, please visit https://www.ihpba.org/14_FeesApplications.html

2. Are you in independent practice? Completed all training and in practice without supervision or retired.

Yes, I am in independent practiceYes, I am retiredNo, I have not yet completed all training

This registry is for individuals who are currently in practice or retired and excludes, medical students, residents, trainees and fellows.

3. Region*
4. Name*

Prefix (Dr, Prof, Mr, Ms, Mrs, Mx, Other) First NameFamily Name
5. Institution*
6. Email*
example@example.com
CC Email Address
example@example.com
7. Mobile Phone Number*

Country CodePhone Number
8. Country*
9. City*
10. Gender*
Collecting gender identity data can help us identify gaps and develop resources to address disparities.
If not listed please describe your gender
11. Date of Birth*

DayMonthYear
12. Describe your Ethnicity*
Collecting data on ethnicity can help us identify gaps and develop resources to address disparities.
Ethnicity Other/Prefer to self describe
13. Are you a Member of a National Chapter*

YesNo
National Chapter
14. Please confirm your clinical focused expertise (select all that apply)*

Benign biliary diseaseBenign liver diseaseCholangiocarcinomaColorectal liver metastasesHepatocellular carcinomaGallbladder cancerPancreatic adenocarcinomaPancreatic cystic neoplasmsPancreatitisNeuroendocrine tumorsTransplantOther
Please confirm your research focused expertise
15. Type of Research (select all that apply)*

Clinical epidemiologyHealth services researchClinical trialsBasic sciencesTranslational sciencesEmerging technologiesGlobal surgeryOther
Research topics:
16. Please confirm whether you are able to give a presentation, chair a session or both?*

Give a presentationChair a sessionGive a presentation and Chair a session
17. Are you comfortable to present in English*

YesNo
Please confirm any other languages you are able to present in
18. Please select your Academic Rank?*

Lecturer/InstructorAssistant ProfessorAssociate ProfessorFull ProfessorProfessor EmeritusOther
If other Academic Rank please detail:
19. What year did you enter independent practice?*
Consent
I consent to the IHPBA Management Office retaining my information for the IHPBA Faculty Directory and contacting me by email*

YesNo
I consent to the details collected on this form being passed on to the IHPBA Scientific Programme Committee*

YesNo
I consent to my details (name, email, insitution, country, expertise and experience ) being published in the faculty directory on the IHPBA website*

YesNo
Thank you!
Should be Empty:

IHPBA Faculty Directory

Please confirm your research focused expertise

Consent

Thank you!