Crohn’s & Colitis Foundation of America (CCFA)
National Scientific Advisory Committee (NSAC) 2015-18 – Application
Name (First, Last):
Degree(s):
Institution or Practice Name:
Address:
City/State/Zip Code:
Phone Number:
Email Address:
Preference on contact method, please underline one: Phone
Email
Gender, please select one:
 Male
 Female
 Other, please indicate
 Decline to answer
Ethnicity origin (or Race), please select the one you most identify with:

White

Hispanic or Latino

Black or African American

Native American or American Indian

Asian / Pacific Islander

Other, please indicate

Decline to answer
Practice Description, please circle one
 Academic/University Practice
 Private Practice
 Accountable Care Organization/Managed Care Organization/Medical Home
 Other: (please describe)
Are you a current member of CCFA?
Yes
No
Are you a member of the local chapter’s medical advisory or mission committee?
Are you a recipient of a CCFA grant or training award?
Yes
If yes, please specify grant/award type and period of time:
Yes
No
No
Are you a current member of the CCFA NSAC (2011-2014)?
Yes
No
If a current member of the NSAC, are you interested in acting as a committee chair or co-chair of a standing
committee?
Yes
No
Do you have any special training, experience, or skills that would make you particularly well suited for one or more of
the committees? If so, please briefly describe: __________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Please attach CV or NIH Biosketch.
Below are the current CCFA NSAC committees. Using a ranking from 1 to 3 please indicate the committees you are
interested in serving upon from 2015 – 2018. Use “1” to indicate your 1st choice and “3” indicating your 3rd choice.
Ranking – 1 to
3 scale
CCFA NSAC Committees
(hyper-link to descriptions from CCFA charter)
Program and Advocacy Committees
Government & Industry Affairs
Nursing Initiatives Committee
Patient Education Committee
Pediatric Affairs Committee
Professional Education Committee
Grants Review Committees
Grants Council
Senior Research Awards Committee
Clinical Research Grants Review Committee
Ad Hoc Conflict Review Committee
Research Fellowship Awards Committee
Research Initiatives Committee