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

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
E-Mail Address *
Would you like your e-mail 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 *
Education Type 2
Education School Attended 2
Education 2 Date Completed
Education Type 3
Education School Attended 3
Education 3 Date Completed
Education Type 4
Education School Attended 4
Education 4 Date Completed
Education Type 5
Education School Attended 5
Education 5 Date Completed
Previous/Current Experience 1 (Location and Title)
Years Employed (ex. November 1987 - January 1991 or September 2010-Present)
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)
Nationwide Children's Hospital
700 Children's Drive Columbus, Ohio 43205 614.722.2000