Form Approved Through 8/31/2016
Child Health Research Institute
MD (Clinical) Trainee Application
LEAVE BLANK – FOR SCH USE ONLY.
LS
PI Sal.
Number
Bio
Budget
Panel
Resub.
Date & Time Received
1. TITLE OF PROJECT (Do not exceed 100 characters, including spaces and punctuation.)
2. NOMINATOR NAME (Last, first)
3. RESUBMISSION APPLICATION
4. FELLOW APPLICANT
RESEARCH MENTORS (List up to three)
NAME (Last, first)
Primary Mentor Name:
DEGREE(S)
Name:
POSITION TITLE
Name:
DEPARTMENT, DIVISION
CO-INVESTIGATORS (List up to three)
TELEPHONE, SUNET ID, AND EMAIL ADDRESS
Name:
TEL:
Name:
SUNET ID:
EMAIL:
Yes
Name:
5. HUMAN SUBJECTS RESEARCH
No
No
Yes
5a. IRB APPROVED
No
6. YEAR OF FELLOWSHIP SUPPORTED BY CHRI
Yes
PGY5
PGY6
(Award Period is 7/1/2013 - 6/30/2014)
7. COSTS REQUESTED
(Salary & Fringe only)
8. DEPARTMENTAL FINANCIAL MANAGER TO BE
NOTIFIED IF AWARD IS MADE
8a. ORACLE FINANCIAL ORG CODE
(Ask Financial Manager for 4 capital letters (e.g. WXYZ)
Total Costs ($)
Name:
9. BIOSTAT CONSULTATION
Email:
Phone:
10. SCH CLINICAL RESEARCH COORDINATOR SERVICES
No
Yes
Yes
Spectrum
11. STUDY NAVIGATOR
No
12. PROJECT FUNDING STATUS (Check all that apply)
Other
Yes
12a. EXTERNAL APPLICATION
Not funded
Partially funded
Funding pending
Industry
Foundation
Mentored award
13. PROJECT SUMMARY (Do not exceed 200 words)
SCH Rev. 10/15
No
9a. SPECTRUM/OTHER
Face Page
Funding approved
Departmental
Federal
Other
No
Yes
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BEGIN PROPOSAL HERE
1. Budget Worksheet (Statement of Fellow’s Salary and Fringe Costs)
2. Introduction (Resubmissions only)
3. Research Plan (maximum 3 pages)
a. Specific Aims
b. Relevance to Child Health
c.
Background and Significance
d. Preliminary Studies (if available)
e. Research Design and Methods
f.
Career Development
g. Potential Pitfalls and Contingency Plans
h. Future Steps
4. Appendix (Figures and References) (maximum 3 pages)
5. Supporting Documents
a. Applicant Information
i. Updated Curriculum vitae
ii. Personal Statement (maximum 2 pages)
iii. Evidence of Acceptance into Fellowship Training Program
iv. Evaluation by 3 Referees (excluding mentors and co-investigators)
v. Documentation of External Funding Application (during the first 15 months of initial fellowship training)
b. Supervisor/ Primary Research Mentor Information
i. Applicant Assessment (maximum 1 page)
ii. Mentoring Plan (maximum 2 pages)
iii. Updated Curriculum vitae
iv. NIH Biosketch and Other Support Page
v. Description of Laboratory, Trainees, Agreement to restriction of clinical duties
c.
Non-Primary Mentor Information
i. Letters of Support
ii. Updated Curriculum vitae
iii. NIH Biographical Sketches (maximum 5 pages per person)
d. Co-Investigator Information
i. Letters of Support
ii. NIH Biographical Sketches (maximum 5 pages per person)
e. IRB Approval (if applicable)
SCH Rev. 10/15
Last name:
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