Social Biography Information Form :: Nationwide Children's Hospital

New Profile Information Form

Please fill out the form below to request a profile on the Nationwide Children's Hospital's website. If you have any questions, please contact

Please note:  If you already have a profile on the website, please fill out the Update Your Profile form. To see if you already have a profile page, please search your first and last name in the search bar in the upper right corner of the website.

If you would like to have your CV included in your profile, please e-mail a PDF version to

*=Required field

Information Form
First Name *
Middle Name/Initial *
Last Name *
Suffix (Sr., Jr., III)
Professional Title (MD, DO, PhD, PT, APN, etc.) *
Hospital Department/ Specialty *
Other - Please indicate here
Gender *
Appointment Date (Date Started at Nationwide Children's Hospital) *
Professional Biography - (A brief paragraph about you and your work written in the third person, please limit to 200 words or less)
OSU ID for Research in View (Ex. Smith.1)
Office Address (will display on the public website) *
Office City *
Office State *
Office Zip Code *
Office Phone *
Office Fax
Email Address *
Would you like your email to show on the public site? *
Secondary Office Address
Secondary Office City
Secondary Office State
Secondary Office Zip Code
Secondary Office Phone
Secondary Office Fax
If you have an OSU ID, we will pull your publications directly from RIV.
If you DO NOT have an OSU ID or a RIV account, please enter the PubMed IDs of your publications below.
Publication 1 (Please provide PubMed ID only)
Publication 2 (PubMed ID)
Publication 3 (PubMed ID)
Publication 4 (PubMed ID)
Publication 5 (PubMed ID)
Should you want to include more publications, please e-mail
Education Type 1 *
Education School Attended 1 *
Education 1 Date Completed (Month, Day and Year) *
Education Type 2
Education School Attended 2
Education 2 Date Completed (Month, Day and Year)
Education Type 3
Education School Attended 3
Education 3 Date Completed (Month, Day and Year)
Education Type 4
Education School Attended 4
Education 4 Date Completed (Month, Day and Year)
Education Type 5
Education School Attended 5
Education 5 Date Completed (Month, Day and Year)
Previous/Current Experience 1 (Location and Title - Ex. Nationwide Children's Hospital, Physical Therapist)
Years Employed (Ex. 2010 - Present, 2005 - 2009)
Previous/ Current Experience 2 (Location and Title)
Years Employed
Previous/ Current Experience 3 (Location and Title)
Years Employed
Previous/ Current Experience 4 (Location and Title)
Years Employed
Previous/ Current Experience 5 (Location and Title)
Years Employed
Professional Memberships (Organizations, Titles, Years Involved - i.e. 2006 - Present) Please do not abbreviate organization names
Awards Received (Award Name, Year Received)
Practice Website
NPI Number
Languages Spoken
Clinical Areas of Interest
Research Areas of Interest
Personal Areas of Interest
Research Funding (Description and Funding Source)
If you need a headshot taken, please contact Kiersten Kollins in Medical Staff Photography.
Have you had a headshot taken at Nationwide Children's Hospital? *
Nationwide Children's Hospital
700 Children's Drive Columbus, Ohio 43205 614.722.2000