OMB#: 0925-0766 Exp Date: 09/2026

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted on-line to complete this instrument so that we can improve the website.

Public reporting burden for this collection of information is estimated to average no more than 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0766). Do not return the completed form to this address.

Privacy Act Statement:

First and last name, email address, and affiliation is primarily collected to submit a nomination and any follow up for clarification or program development. If you do not provide this information, you would not be able to submit a nomination. Providing telephone number and additional contact information is optional. Collection of this information is authorized under 42 U.S.C. 203, 241, 289l-1 and 44 U.S.C. 3101, and Section 301 and 493 of the Public Health Service Act. The Privacy Act System of Records Notice (SORN) that covers collection of this information 09-25-0156 Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD and 09-90-1901 HHS Correspondence, Comment, Customer Service, and Contact List Records.