Information about Nominee

OMB#: 0925-0766 Exp., date: 04/2023
 
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The IPRCC seeks nominations for IPRCC members from scientists, physicians and health professionals who are leaders in the field of pain research; and members of the general public who are representatives of leading research, advocacy and service organizations for individuals with pain-related conditions.
 
The Department is soliciting nominations for one non-federal member from among scientists, physicians, and other health professionals and for two non-federal members of the general public who represent a leading research, advocacy, or service organization for people with pain-­related conditions. These candidates will be considered to fill positions opened through completion of current member terms.
 
The current membership of the IPRCC can be viewed here:  See the current membership roster of the IPRCC.
 
In an effort to standardize the nomination process for an efficient and fair process, the Office of Pain Policy and Planning has created this form to facilitate nominations. Nominees for the scientific member slots will be evaluated based on nomination letters, CV and five criteria: 1) Pain­-relevant publication record; 2) Public service; 3) Leadership; 4) Funding record; and 5) Clinical activities (if relevant). Nominees for the public advocate slots will also be evaluated based on nomination letters, CV and three criteria: 1) Public service; 2) Leadership; and 3) Merits of organization.
 
Nominations are due by COB: November 30, 2022 For additional information please see the Federal Register Notice.

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* 1. First Name

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* 2. Last Name

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* 3. Degree(s) (if any)

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* 4. Title

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* 5. Organization

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* 6. Areas of Expertise

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* 7. State of Residence

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* 9. Pain-relevant publication Record

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* 10. Public Service

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* 11. Leadership

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* 12. Funding Record

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* 13. Clinical Experience

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* 14. Please attach a CV

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Information about Nominator

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* 15. First Name

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* 16. Last Name

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* 17. Degree(s) (if any)

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* 18. Title

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* 19. Organization

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* 20. Affiliation with nominee

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* 21. Please attach a nomination letter

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