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Institute of Genetic Medicine Data Collection Form

Please complete the following form on yourself and all of your staff and trainees. Your participation is greatly appreciated. If you have any technical difficulties with this process, please contact the
IGM webmaster.

First Name «

Last Name «

Suffix «

Please select all that apply. Multiple entries are selected by using the control key.

If You Picked Other?

Suffix?

Date of Birth

Date of Hire

Office or Lab Address «

Complete. Building, Street and Room Number

Telephone «

7-digit

Fax Number «

7-digit

Email Address «

Position «

Job description

If You Pick Other?

Position Title/Role in IGM

If a graduate student, program enrolled?

Laboratory or Program Supervisor «

Supervisors Email

United States Citizen?

Yes No

If No, Citizenship?

Visa Status

Must be completed if non US Citizen

Visa Expiration

Fields marked with « are required.

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