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Brain Injury Canada Scientific Advisory Committee Intake Form

Before completing the following form, please read the following documents:

Conflict of Interest
Scientific Advisory Committee Agreement

Name (including academic degree and/or designations) *

Email Address *

Profession *

Title *

Organization *

If you have multiple titles & organizations/institution affiliations, please list them here

Province/Territory *

Which types of brain injuries do you most regularly work with in practice or in research? *Concussion (mild traumatic brain injury)Moderate to severe traumatic brain injuryNon-traumatic brain injury (Tumour, stroke, etc.)

Area(s) of expertise *Activities of Daily Living (ADLs)Aging/seniors & brain injuryBehaviourCaregiving/caregiver wellbeingCognitionCommunicationCriminal justiceDiscriminationEmergency medicineEmotional health & wellbeingEmployment/vocational rehabilitationFallsFinancial literacy/planningGender & sexual identityHearing/aural healthHousing/homelessnessIndigenous healthIntensive careIntimate partner violenceKinesiologyLife care planningLong-term careMental healthMobilityNeurologyNeuro-psychologyNutritionOccupational therapyOverdose & brain injuryPhysiatryPhysiotherapyPsychologyRecreationSocial workSpecial education/disability educationSpeech-language pathologySports injuries (concussions)StrokeSubstance use (including alcohol and/or opioids)VisionPlease select all areas of research/instruction that apply to you. E.g. caregiver wellbeing, substance use, housing, etc. Please write in any area(s) of expertise not included in this list.

OtherIf you have an additional area(s) of expertise, please include here

Please select the demographics you work with/research regularly *Pediatric (under 18)AdultSenior (65+)

Please include a short bio about yourself & your work/research *

If there is anything else you would like us to know, please include it here

I confirm I have read and agree to the Conflict of Interest statement *Yes

I confirm I have read and agree to the Scientific Advisory Committee Agreement *Yes

I give my permission for my name, title, and institution/organization(s) on the Brain Injury Canada website *YesNoWe do not post contact information on our website

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