NIMH MEDICAL STUDENT FELLOWSHIP PROGRAM in MENTAL HEALTH RESEARCH
MEDICAL STUDENT APPLICATION
Academic Year 2014-2015
PERSONAL INFORMATION
Name ________________________________________________
Last
First
MI
Place of Birth __________________________________________ Citizen of: ____________________
Undergraduate Institution and Major ______________________________________________________
Medical School Institution________________________________ Expected Graduation Date: __________
(Current Year in Medical School ___________)
Prior Research Experience? ___Yes ___No
If Yes, number of academic terms in which you have participated in such research: ____
ADDRESSES
Campus Address
Summer Address
_____________________________
Campus Phone
_____________________________
Day (
_____________________________
City
ST
ZIP
Eve ( ) ___________________
Valid Until: ___________________
(MONTH/DAY/YEAR)
_____________________________
Email
_____________________________
_____________________________
Valid Until:____________________
(MONTH/DAY/YEAR)
_____________________________
Permanent Address ____________________________
(e.g., parents;
other family
____________________________
member)
____________________________
City
ST
ZIP
Phone (
)
___________________
) __________________
(Full Undergraduate and Medical School Transcripts are Required)
OPTIONAL INFORMATION
Race/Ethnic Status (Check all that apply)
Sex
Date of Birth
__ African American
__ Asian/Pacific Islander
__ Male
(MO/DAY/YR)
__ Hispanic
__ American Indian/Alaskan
__ Female
_____________
__ Caucasian
__ Other (Specify)
Disability
__ None
__ Auditory
__ Motor/Physical
__ Visual
__ Other (Specify)
EDUCATIONAL BACKGROUND/GOALS
Completed Undergraduate Coursework (Please enter information below, in addition to sending official
transcript):
Biochemistry
Cell Biology
Cognitive Psychology
Developmental Psychology
Genetics
Independent Research
Molecular Biology
Neuroanatomy
Neuroscience
Organic Chemistry
Psychobiology
(Biological Psychology,
Physiological Psychology)
Title
Grade
Term/Year
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Other Relevant Courses Taken:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
List courses relevant to your educational goals which you will complete before graduation but which might
not be listed on your current transcript:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Preferred Areas of Research Interest. Please rank top four areas (1 = Highest):
__ Mood Disorders
__ Biological Chemistry
__ Biological Psychiatry
__ Child/Adolescent Mental Disorders
(e.g., autism, attention deficit
disorders, eating disorders)
__ Clinical Neuroscience
__ Neurology
__ Neuropsychiatry
__ Neurosurgery,
__ Neuropsychology
__ Neuropharmacology
__ Clinical Pharmacology
__ Clinical Psychology
__ Cognitive Neuroscience
__ Cognitive Psychology
__ Mental Health in Primary Care
__ Developmental Neuroanatomy
__ Developmental Psychology
__ Health Psychology/ Behavioral Medicine
__ Human Genetics
__ Molecular or Cell Biology
__ Neuroscience (Basic)
__ Schizophrenia
__ Addictive Disorders
__ A Specific Psychiatric Disorder
(Specify): _________________________
__ Anxiety Disorders (e.g. Panic, PTSD)
Other (Specify):
___________________________________
___________________________________
___________________________________
Indicate the area(s) of your interest in future research (use separate sheet if necessary):
_______________________________________________________________________________________
_______________________________________________________________________________________
College, university, or medical school honors received (scholarships, fellowships, honor societies, etc.):
_______________________________________________________________________________________
_______________________________________________________________________________________
Publications (give full citation, i.e. authors, title, publication, year, and page numbers. Use separate sheet
if necessary):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
REFERENCES (Request letters from two faculty members who best know your academic and research
work, in addition to the preceptor with whom you wish to work. Please list these references here.)
1) Name of Preceptor/Mentor: _____________________
3) Name:________________________________
Department:
_________________________________
Department: _____________________________
Institution:
_________________________________
Institution: ______________________________
Phone:
__________________________
Phone: _______________________
2) Name: _____________________________________
4) (OPTIONAL)
Name: _________________________________
Department:
_________________________________
Department: _____________________________
Institution:
____________________________
Institution: ______________________________
Phone:
_____________________
Phone:
________________________
ADDITIONAL MATERIALS (These must be submitted before an application can be reviewed)
1)
STATEMENT OF ACADEMIC INTERESTS AND CAREER GOALS
This statement should be typed and 1-2 pages long. Include your intentions regarding post-medical school,
education, training, and career goals. Describe your interest in mental health-related sciences. Consider how
this Fellowship Program in Mental Health Research may be relevant to your educational and career goals.
Include information regarding any previous research and clinical experience you have had and any
publications to which you have contributed.
2)
THREE LETTERS OF REFERENCE FROM ACADEMIC FACULTY (INCLUDING ONE
FROM THE IDENTIFIED PRECEPTOR/MENTOR)
To be sent directly to the Program Director from the three persons named above.
3)
OFFICIAL TRANSCRIPTS – UNDERGRADUATE This should include all college work..
4)
OFFICIAL TRANSCRIPT – MEDICAL SCHOOL This should include all terms.
Return to:
Gretchen L. Haas, Ph.D.
Program Director
NIMH Medical Student Fellowship in Mental Health Research
University of Pittsburgh School of Medicine
Western Psychiatric Institute and Clinic
3811 O'Hara Street
Keystone Building, Room 705
Pittsburgh, Pennsylvania 15213
Telephone: (412) 383-5467
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Applicant’s Signature
______________________________
Date