CAIRIBU Conference & Data Dissemination Grant LinkedInThis field is for validation purposes and should be left unchanged.Applicant InformationBe sure to read the CAIRIBU Conference and Data Dissemination Grant description before completing this application. For more information about this grant or about completing this application, contact CAIRIBU Interactions Core Director, Dr. Kristina Penniston, penn@urology.wisc.edu.Applicant's Name(Required) Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Applicant's Institution Name(Required)Institution Address(Required)Applicant's Telephone(Required)Applicant's Email(Required) Enter Email Confirm Email Which of the following best describes you?(Required) Female Male Other Prefer not to answer What is your race or ethnicity? (Check all that apply)(Required) White- For example, German, Irish, English, Italian, Polish, French, etc. Hispanic, Latinx, or Spanish origin- For example, Mexican or Mexican American, Puerto Rican, Cuban, Salvadoran, Dominican, Colombian, etc. Black or African American- For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc. Asian- For example, Chinese, Filipino, Indian, Vietnamese, Korean, Japanese, Pakistani, etc. American Indian or Alaska Native- For example, Navajo Nation, Blackfeet Tribe, Mayan, Aztec, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, etc. Middle Eastern or North African- For example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, Algerian, etc. Native Hawaiian or Other Pacific Islander- For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc. Other Prefer not to answer Do you have a physical or mental impairment that substantially limits one or more major life activities, as described in the Americans with Disabilities Act of 1990?(Required) Yes No Don’t know Prefer not to answer Do you meet two or more of the disadvantaged background criteria below?(Required) Yes No Don’t know Prefer not to answer Individuals from disadvantaged backgrounds are defined by the NIH as those who meet two or more of the following criteria: *Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act *Were or currently are in the foster care system, as defined by the Administration for Children and Families *Were eligible for the Federal Free and Reduced Lunch Program for two or more years *Have/had NO parents or legal guardians who completed a bachelor’s degree (see First-Generation and Continuing-Generation College Students: A Comparison of High School and Postsecondary Experiences *Were or currently are eligible for Federal Pell grants Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child *Grew up in one of the following areas: (a) a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural Health Grants Eligibility Analyzer, or (b) a Centers for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage AreasInformation About EventStart Date(Required) If the event takes place on a single day, please fill in the same date on both Start Date and End Date.End Date(Required) Event Location – Institution(Required)Title of event (e.g., name of symposium or workshop)(Required)Describe how you will benefit from participating in the event.Applicant's role in event(Required) Abstract Poster Lecture or other presentation Attendee (no poster or presentation) Title of abstract, poster, or presentation(Required)If not submitting an abstract, presenting a poster, or delivering a presentation, enter NA in the space aboveApplicant's career stage(Required) Early investigator (within 10 years of terminal degree or initial academic appointment) K scholar Post-doctoral researcher Student Information about the person nominating the applicantIf you have been invited or otherwise nominated to apply for this award, provide the name and email address of this person. Otherwise leave this section blank.Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Email FILE UPLOADIf the organizers of the event for which you are applying for a Conference & Data Dissemination Grant require an abstract or written statement, upload it as a SINGLE PDF document below.FileMax. file size: 10 MB.