Centers of Excellence Application SRNA’s goal is to establish additional Centers of Excellence focused on providing clinical care, advancing research to better understand rare neuroimmune disorders and developing more effective acute therapies and symptom management strategies. It is our intent to partner with the clinicians at the Centers of Excellence and support through funding (when available through Board approval) for innovative, promising research ideas. APPLICATION INSTRUCTIONS For any text attachments for the online application form, use standard size black type no smaller than 11 point; do not use photo reduction. Copies of any preprints, reprints, or other additional materials must be submitted with the application. The application must be submitted accompanied by all supporting documents. Please do not submit your application until you have assembled all requested materials. For more about the goals of the Centers of Excellence designation, please visit – https://wearesrna.org/shaping-the-future/our-programs/centers-of-excellence-in-rare-neuroimmune-disorders-cernd/?swcfpc=1 If you have any questions about the preparation of your application, please contact Krissy Dilger at kdilger@wearesrna.org Question Title * 1. Institution Information Name of Site Director * Title * Institution * Institution's Address * City/Town * State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Institution's Fax Number * Email Address * Institution's Phone Number * Question Title * 2. Please attach the CV(s) of the site director(s). Please combine all CVs into one document if more than one. PDF, DOC, DOCX, PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please combine all CVs into one document if more than one. Question Title * 3. Please attach bios for any other relevant site staff. Please combine all bios into one document if more than one. PDF, DOC, DOCX, PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please combine all bios into one document if more than one. Question Title * 4. Why are you interested in being a SRNA designated Center of Excellence? Question Title * 5. What are your research interests and what research studies are you currently a lead investigator on? Question Title * 6. Please attach any relevant research publications at your center. Please combine all publications into one document if more than one. PDF, DOC, DOCX, PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File Please combine all publications into one document if more than one. Question Title * 7. Do you have residency and/or fellowship programs? Question Title * 8. Please indicate which of the following disciplines are included in your center: Neurology/Neuroimmunology Neuro-ophthalmology Neuropsychology/Psychiatry Neuroradiology Nutrition Occupational therapy Orthopedics Physiatry Physical therapy Rehabilitation Social work Urology Question Title * 9. Please provide an approximate number of acute patients you see per year. Pediatric Patients Adult Patients Question Title * 10. Please provide an approximate number of long-term patients you see per year. Pediatric Patients Adult Patients Question Title * 11. Do you offer IV steroids at your center? Yes No Question Title * 12. Do you offer plasmapheresis at your center? Yes No Question Title * 13. Do you offer IVIG at your center? Yes No Question Title * 14. Do you offer Cyclophosphamide at your center? Yes No Question Title * 15. Does your center have a rehabilitation facility? Yes No Question Title * 16. If not, is your center affiliated with a local rehabilitation facility? Yes No Not applicable Question Title * 17. Does the rehabilitation facility treat adults? Yes No Not applicable Question Title * 18. Does the rehabilitation facility treat children? Yes No Not applicable Question Title * 19. Are you a member of SRNA? (If no, please fill out the membership form here before completing the application.) Yes No Question Title * 20. Which SRNA programs, if any, have you participated in or contributed to? Programs include podcasts, Family Camp, symposia, support groups, etc.? Podcast(s) Family Camp Rare Neuroimmune Disorders Symposium Support Group(s) Other (please specify) None of the above Question Title * 21. Anything else we should know? Done