New and Established Investigators Network of Expertise (NoE) Application
Thank you for your interest in joining the New or Established Investigators NoE! We are excited that you are interested in joining our network of dedicated members who share a mutual passion for dissemination and implementation work. Please fill out the application below. If accepted, the information you provide will be featured on our NoE pages on the SIRC website if you consent. The information you provide will be extremely helpful for identifying mentorship matches and supporting general networking among SIRC members.
Sign in to Google to save your progress. Learn more
Please send your CV to with "CV for New/Established NoE Application" in the subject line.
Which NoE are you applying for?
Clear selection
Name & Degree (e.g., Jane Doe, MD, PhD): *
E-mail: *
Role/Position(s) (e.g., Department Chair, Professor, Director): *
University, Organization, and/or Program Affiliation(s) (e.g., UCLA, Kaiser Permanente, Save the Children): *
Please enter 3 – 5 keywords that will help others understand your expertise. Please consider: 1) General area(s) of interest (e.g., behavioral health, addictions, health, education, human services, etc.), 2) Implementation area(s) of interest (e.g., mechanisms, sustainability, fidelity, adaptation, scale-up, de-implementation, dissemination, adoption, direct-to-consumer, policy, UCD, DMH, learning collaboratives, consultation, system redesign, etc.), and 3) Sub-population/group(s) of interest (i.e., veterans, children, LMICs, etc.):
Have you secured any dissemination & implementation-related funding (e.g., grants, K-awards, fellowships)? If yes, please write which grants. *
If you have one, please insert a link to your website profile (e.g., personal website, lab website, school website, ResearchGate): *
What's your Twitter handle? (e.g., @margaret_crane1, @StephanieHtYu) *
If accepted, would you consent to having the information above featured on our SIRC Investigators NoE Website (e.g., name, degree, role/position, affiliation, research area key words, website, Twitter)? This will be particularly helpful for identifying mentors for SIRC NoE mentorship. If you only want some information featured on our SIRC Investigators NoE website, please indicate which categories here:
How has dissemination and implementation influenced your thinking about research to date? *
Which initiatives are you willing to participate in as an active member of the NoE (check all that apply)? *
Which mentorship models would you be willing to provide for other SIRC members?
How frequently are you willing to provide mentorship?
What are your interests in research, clinical, and/or D&I practice? Please respond with information to help us make mentorship matches.
What are you specifically able to provide mentorship on? Possible examples include: general mentorship (e.g., long-term career planning, prioritizing projects); research collaboration opportunities; learning more about D&I; grant writing; workshopping an idea; dissertation execution mentorship on.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Google Apps for UCLA. Report Abuse