{"id":4440,"date":"2023-01-27T12:35:22","date_gmt":"2023-01-27T17:35:22","guid":{"rendered":"https:\/\/www.med.unc.edu\/hr\/?page_id=4440"},"modified":"2024-06-06T16:47:18","modified_gmt":"2024-06-06T20:47:18","slug":"school-of-medicine-affiliate-request","status":"publish","type":"page","link":"https:\/\/www.med.unc.edu\/hr\/school-of-medicine-affiliate-request\/","title":{"rendered":"School of Medicine Affiliate Request"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">SOM Affiliate Request<\/h2>\n                            <p class='gform_description'>Request School of Medicine Affiliation for Hospital Associates and Research Collaborators<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/hr\/wp-json\/wp\/v2\/pages\/4440\/' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_33\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_33\" ><h3 class=\"gsection_title\">Business Justification and Access Needs<\/h3><\/div><div id=\"field_2_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\" ><label class='gfield_label gform-field-label' for='input_2_34'>Please outline the business justification for needing a School of Medicine affiliation, including each of the websites, systems, or shared drives you need access to:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_2_34' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_35\" ><h3 class=\"gsection_title\">Department and Sponsor Details<\/h3><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\" ><label class='gfield_label gform-field-label' for='input_2_13'>Please list the School of Medicine Department or Center you are working with:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\" ><label class='gfield_label gform-field-label' for='input_2_14'>Please list the first and last name of your School of Medicine sponsor, PI, or residency director associated with your affiliate request:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_32\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\" ><h3 class=\"gsection_title\">Details of Person Needing Affiliate Status<\/h3><\/div><fieldset id=\"field_2_27\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please provide your full name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_2_27'>\n                            \n                            <span id='input_2_27_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.3' id='input_2_27_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_27_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_2_27_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.4' id='input_2_27_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_27_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_2_27_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.6' id='input_2_27_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_27_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><label class='gfield_label gform-field-label' for='input_2_5'>Birth Date:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_2_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_5_date_format gfield_description_2_5\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_5' class='gform_hidden' value='https:\/\/www.med.unc.edu\/hr\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_2_5'>Date of Birth<\/div><\/div><div id=\"field_2_25\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\" ><label class='gfield_label gform-field-label' for='input_2_25'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_2_25' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Male<\/option><option value='Female' >Female<\/option><option value='My gender is not listed' >My gender is not listed<\/option><\/select><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_9\" ><label class='gfield_label gform-field-label' for='input_2_9'>Primary Phone #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\" ><label class='gfield_label gform-field-label' for='input_2_17'>PID (If Known)<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_31\" class=\"gfield gfield--type-multi_choice gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  data-js-reload=\"field_2_31\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please select your primary employer:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_31'>\n\t\t\t<div class='gchoice gchoice_2_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='First Choice'  id='choice_2_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_0' id='label_2_31_0' class='gform-field-label gform-field-label--type-inline'>大象传媒 Health<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Second Choice'  id='choice_2_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_1' id='label_2_31_1' class='gform-field-label gform-field-label--type-inline'>大象传媒 Rex<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Third Choice'  id='choice_2_31_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_2' id='label_2_31_2' class='gform-field-label gform-field-label--type-inline'>NC Health<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_31_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='gf_other_choice'  id='choice_2_31_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_31_3' id='label_2_31_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_2_31_other' class='gchoice_other_control' name='input_31_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\" ><label class='gfield_label gform-field-label' for='input_2_26'>Please select your Benefits Plan, if applicable:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_2_26' class='large gfield_select'  aria-describedby=\"gfield_description_2_26\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='State Benefits' >State Benefits (State Health Plan)<\/option><option value='NC Health Benefits' >NC Health Benefits (NC Health Plan)<\/option><option value='No Benefits' >I do not receive benefits<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_26'>Do you get your benefits through NC Health Benefits or through State Benefits?<\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\" ><label class='gfield_label gform-field-label' for='input_2_19'>Please enter your email contact:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_19' id='input_2_19' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_2_23\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please enter your home address:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_23' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_23_1_container' >\n                                        <input type='text' name='input_23.1' id='input_2_23_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_23_1' id='input_2_23_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_23_2_container' >\n                                        <input type='text' name='input_23.2' id='input_2_23_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_23_2' id='input_2_23_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_23_3_container' >\n                                    <input type='text' name='input_23.3' id='input_2_23_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_23_3' id='input_2_23_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_23_4_container' >\n                                        <select name='input_23.4' id='input_2_23_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_2_23_4' id='input_2_23_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_23_5_container' >\n                                    <input type='text' name='input_23.5' id='input_2_23_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_23_5' id='input_2_23_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_23.6' id='input_2_23_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_2_24\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please enter your business address:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_24' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_24_1_container' >\n                                        <input type='text' name='input_24.1' id='input_2_24_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_24_1' id='input_2_24_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_24_2_container' >\n                                        <input type='text' name='input_24.2' id='input_2_24_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_24_2' id='input_2_24_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_24_3_container' >\n                                    <input type='text' name='input_24.3' id='input_2_24_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_24_3' id='input_2_24_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_24_4_container' >\n                                        <select name='input_24.4' id='input_2_24_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option 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