Resident / Clinical Fellow Approval Form
(Use this form when a resident fellow or clinical fellow is to be PI
or receive salary support from and/or devote effort to a sponsored project.)
A. Candidate’s Information
Name:
Mentor’s name:
Department:
Phone:
Phone:
Email Address:
Email Address:
Position:
Resident Fellow
Clinical Fellow
PGY Level:
Duration of Clinical Training (please enter start and end date):
This will be a:
research intensive period;
clinically intensive period.
B. Project Information
Funding Agency:
Funding Opportunity Announcement:
(Provide FOA# and title if available.)
Project Title:
In what capacity are you participating in this project?
Level of Effort:
%
as support staff
as PI (verify PI eligibility with your RPM)
Project Period (start and end dates):
Note: The level of effort should be minimal during clinically intensive years.
C. Dept Program Director
Dept Program Director’s name:
How will the proposed research be integrated into the candidate’s clinical training?
(Please do not exceed 7 lines.)
I have reviewed the information on this form. The clinical training experience is a full time experience, however the
candidate is at a stage in his/her career where partaking in a research project is feasible. I certify that the candidate
named above has release time to participate in this project. If the candidate is a resident, I certify that the candidate will
not be in violation of the 80hr work week.
Signature: __________________________________________________________
SB 09/24/2013
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Date:
D. Director of Finance and Administration or Division Manager
Candidate’s Annual Salary: $
Does the Hospital provide any salary support for the Candidate?
Yes
No. If yes, how much? $
Will the hospital provide release time in order to offset the candidate’s effort on the project?
Will salary be directly charged to this sponsored project?
Yes
Yes
No.
No. If yes, how much? $
Note: In order for salary to be directly charged to the project, the fellow must have an academic appointment. In order
to pursue an academic appointment, the hospital must provide release time.
Mark the appropriate box:
The candidate will not obtain salary support from this sponsored project.
Salary support from this sponsored project will be utilized to replace another funding source.
Salary support from this sponsored project will supplement the candidate’s current salary.
I certify that (1) the candidate’s annual salary is commensurate with other residents/clinical fellows at the same level of
experience and in the same program; (2) if effort will be directly charged to this sponsored project, an award will not be
accepted until the candidate obtains an academic appointment (e.g. postdoc or instructor appointment) that is
commensurate with the level of effort devoted on this project..
Note: If the fellow has indicated he/she will be PI on the project, the fellow must have an academic appointment and
meet PI eligibility requirements (refer to RPH 2.1 http://rph.stanford.edu/2-4.html ).
Signature: __________________________________________________________
Date:
E. Office of Postdoctoral Affairs
I approve this request. If the candidate named above is identified as the PI on this project, I understand that the
candidate must have an academic appointment in order to accept an award. The candidate may be appointed as a
postdoctoral fellow or as an instructor with an appointment that can support the level of effort identified in the proposal.
I do not approve this request.
If not approved, please explain:
Approval (signature): ______________________________________________
Authorized Designee, Office of Postdoctoral Affairs
Date:
Once all signatures have been obtained, please scan the form and email the form to your Research Process
Manager in the Research Managment Group.
Name:
Email Address:
Research Managment Group
Stanford University, School of Medicine
3172 Porter Drive
Palo Alto, CA 94304-1212
Fax: 650-498-5876
SB 09/24/2013
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