(11/2015)
Summer Research Elective Credit
Documentation of Research and Final Approval Form
Use this form to complete your application for 4 weeks of elective credit for ≥ 8 weeks of Summer Research conducted
between the first and second year of medical school.
Deadline:
This form must be submitted by October 1st after completion of the summer research experience.
Instructions:
1) THIS FORM MUST BE COMPLETED IN ADOBE ACROBAT PRO, which can be found on the medical library
computers.
Download and save the form before filling it in.
2) Save the form with the following file name: FinalApp_Class_LastName.pdf (e.g. FinalApp_2019_Doe.pdf)
3) Obtain your mentor’s digital signature. Alternatively, a scanned copy of the hand-signed signature page may be
attached as a separate file.
4) Submit the electronic form (and, if needed, the scanned signature page) by email to:
medstudentresearch@med.cornell.edu
Date:
Student Information:
First Name:
Last Name
Email Address:
Class (YYYY)
Sex (check one):
Project Title (create one now if necessary):
Dates:
Start Date:
End Date:
Mentor Information
Name:
Address:
Title:
Department:
Phone Number:
Institution:
Email Address:
Male
Female
Description of the Experience:
Background/
Significance:
Max words - 300
Describe the problem that was studied and why it is scientifically/clinically important.
Aims/
Hypothesis:
Max words - 175
Explicitly state the principal aims of the study and the hypothesis that you proposed to test.
Methods:
Max words – 250
As appropriate, describe study type, sample selection, inclusion criteria, techniques, materials, experimental design, study
variables, outcome measures, etc.
Description of Experience: (continued)
Summary
of Results:
Max words - 350
Conclusions/
Future Plans:
Max words - 350
Briefly describe the conclusions of your studies and their significance, as well as potential next steps for the project. You may also
use this section to describe any technical difficulties or unforeseen problems completing the project as originally describes in your
Pre-Approved study form.
Specific
Involvement:
Max words - 175
Briefly describe your specific involvement in the project (e.g. conducted experiments, recruited subjects, analyzed data, wrote
manuscript etc.)
Additional
Information:
Max words - 100
Please provide any additional information that you deem relevant (optional).
How was this work funded? Check all that apply:
Federal Work-Study Program
CTSC Award
Mentor/PI/Lab Funding
Unfunded
Extramural Agency (Foundation/Society/NIH), Please specify:
What is the nature of this project? Check all that apply:
Basic Science
Clinical Medicine
Medical Ethics
Other (Specify):
Community Health
Global Health
Epidemiological
Publications/Presentations:
Please indicate if you plan to submit your work for peer-reviewed presentation or publication. Check all that apply.
This work has been published.
This work has been presented.
This work has been submitted for publication.
This work has been submitted for presentation.
This work will be submitted for publication.
This work will be submitted for presentation.
Supporting Materials (wherever appropriate)
Supporting materials are attached as additional PDF files.
Description:
Please describe the supporting materials (e.g. conference abstract, manuscript draft, etc.)
Mentor Approval:
By signing this form, I certify that I have read and verify the accuracy of the experience description provided in this form. I
also confirm that I have read the learning objectives associated with the Summer Research Elective, which can be found
at: http://weill.cornell.edu/education/curriculum/summer_research_experience_lo.html
Name:
Date:
Signature:
For use by Office of Medical Student Research or Curriculum Office only.
Approval of final report and 4 weeks of elective credit:
Name:
Date:
Signature: