RRTP_RRT2015-2016_Main file:///C:/Users/leivac1/AppData/Local/Temp/form.html
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Application instructions.
Please read and follow the following instructions carefully to ensure that you submit an accurate and complete application.
1. Carefully review the program requirements before you begin: http://accelerate.ucsf.edu/funding/fundingfor-residents#travel .
2. You will need to create PDF documents for any parts of the application that may require you to upload a
PDF (e.g. your biosketch, letters of support, research plan, etc).
4. Only PDF formatted documents (no MS Word, Excel, PPT, etc.) may be uploaded to the application. Be sure that the PDF attachments are not password protected or secured.
5. Before you submit your application, we suggest that you review your application for accuracy. You won’t be able to submit the application if required elements are missing.
6. You are only allowed to submit the application once per primary email address. You are responsible for submitting a complete and accurate application. You will receive an email confirmation including a copy of your submitted application. If you discover that you have made a major error after submitting your application, please notify Christian Leiva at Christian.Leiva@ucsf.edu
. Note that changes will be at the discretion of the PROGRAM and must be completed by the deadline.
7. There is no deadline for this application. However, please be advised that an application must be submitted by the 20th of the previous month for consideration the first two weeks of the following month.
Travel should occur after the 15th of the following month at the earliest and no more than six months out at the latest. Please see the example below:
Feb 20: Application due for presentations occurring any time from March 15 to September 15.
First two weeks of March: Any applications received by Feb 20 will be reviewed.
Mar 15 to Sep 15: Any applications that are awarded are for travel to present within this timeframe
First Name*
Last Name*
Middle Initial
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Degree(s) Held*
Master of Arts (MA)
Master of Science (MS)
MAS in Clinical Research
MPH
PhD
MD
Other:
Select all that apply
Home Address* Address Line 1*
Address Line 2
City
State
ZIP Code
Permanent Address (if different from Home Address) Address Line 1
Address Line 2
City
State
ZIP Code
Office Address* Address Line 1*
Address Line 2
City
State
ZIP Code
Primary Email Address*
(work email)
Alternate Email Address*
(personal email; must be different from above)
Home Telephone
Office Telephone*
Mobile Telephone*
Fax file:///C:/Users/leivac1/AppData/Local/Temp/form.html
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Campus*
UCSF
UCSF Fresno
Residency Program*
If Other, please list residency program here:*
Must be in the School of Medicine.
Year of Completion*
In what year will you/do you expect to complete residency?
UCSF Box Number* file:///C:/Users/leivac1/AppData/Local/Temp/form.html
Gender*
Female
Male
Date of Birth*
Month
Day
Year
Citizenship*
U.S. Citizen or Non-citizen National
Non-U.S. Citizen with a permanent US Resident Visa ("Green Card")
Non-U.S. Citizen with a Temporary Visa
If not a U.S. Citizen, of which country are you a citizen?
Are you Hispanic (or Latino)?*
Yes
No
Do not wish to provide
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What is your racial background?*
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Asian
Black or African American
White
Do not wish to provide check all that apply
Have you completed the Designing Clinical Research course?*
Yes
No
If yes, when?*
Month
Day
Year file:///C:/Users/leivac1/AppData/Local/Temp/form.html
If yes, provide the name of your Small Group Leader:
Have you received a CTSI Resident Research Funding (RRF) award for the project in this application?
Yes
No
Have you applied to other funding sources for this travel?
Yes
No
If yes, explain:
Please list the following information about your Program Director.
Program Director's First Name*
Program Director's Last Name*
Program Director's Institution*
UCSF
Other:
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Program Director's School*
Medicine
Nursing
Dentistry
Pharmacy
Program Director's Department*
Program Director's Division
Program Director's UCSF Box Number*
Program Director's Email *
Program Director's Primary Telephone*
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Please list the following information about your Mentor
Mentor's First Name*
Mentor's Last Name*
Mentor's Degree(s)
Master of Arts (MA)
Master of Science (MS)
MAS in Clinical Research
MPH
PhD
MD
MD, PhD
PharmD
DDS
Other:
Select all that apply
Mentor's Institution*
UCSF
Other:
Mentor's School*
Medicine
Nursing
Dentistry
Pharmacy
Mentor's Department*
Mentor's Division
Mentor's UCSF Box Number* file:///C:/Users/leivac1/AppData/Local/Temp/form.html
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Mentor's Email *
Mentor's Primary Telephone*
Conference Name*
Conference Dates*
Please enter in mm-dd-yyyy to mm-dd-yyyy format.
Conference Location*
City and state (city and country if outside the U.S.).
file:///C:/Users/leivac1/AppData/Local/Temp/form.html
Abstract Title*
List up to 3 MeSH terms that best describe your research*
Medical Subject Headings (MeSH) is the National Library of Medicine's vocabulary used for indexing biomedical and health-related information. Go to the NLM link to search terms that best characterize your research. http://www.nlm.nih.gov/mesh/MBrowser.html
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Total Amount Requested from the Resident Research Travel Grant* $
Up to $600.
Submission Fee* $
Enter 0 if none or not applicable.
Conference Registration* $
Enter 0 if none or not applicable.
Travel/Food/Lodging* $
Enter 0 if none or not applicable.
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Materials (poster fees, etc.)* $
Enter 0 if none or not applicable.
Other (please describe below) $
Enter 0 if none or not applicable.
Please explain if Other.
Total Proposed Expenses* $
Total of all expenses; not only what is being requested.
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All attachments must be in PDF format.
Conference Abstract* No file selected.
Please attach a copy of the abstract you have submitted or plan to submit.
Submission Form* No file selected.
Please attach a copy of the completed submission form. This is the form from the conference you are planning to attend used along with the abstract when you submitted the abstract. If you submitted online, this could be a screenshot of the confirmation of submission you receive or an email confirmation that your form was submitted.
Acceptance Forms No file selected.
Please attach a copy of acceptance forms if applicable.
Letter of Support* No file selected.
Please attach a brief letter from your Mentor, Program Director or Department Chair stating the he or she supports the proposal request and if an award is made, that he or she will provide matching funds for your travel. Please have them write it on institution letterhead and include name, title, school, and department.
Letter writer should provide applicant with a copy to upload.
Cancel
Confirm
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