Application for 2009-11
Clinical Research Curriculum
Last Name:
Degrees :
Primary Discipline:
First Name:
Middle
Initial:
Current status:
Status at start of CRC participation:
Academic title at start of course:
Program Director
Name (if fellow at start of course)
Program Director email:
Primary Research
Mentor: (name)
Primary Research
Mentor email:
Applicant ’s
Department:Division:
Seeking a degree?
Have already taken/am taking:
Am currently taking
Requesting for 2009-
10
Email address:
Mailing address (home):
Fellow / postdoc _______PGY
Fellow / postdoc _______PGY
No Yes
MPH MSCR Other:_____________________
EPID 711 BIOS 541 BIOS 542
EPID 805-806
Faculty
Faculty
EPID 711 BIOS 541 BIOS 542 EPID 896
EPID 711 BIOS 541 BIOS 542
EPID 896 EPID 805-806
Telephone (home):
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Application for 2009-11
Clinical Research Curriculum
Mailing address (campus):
NC Resident: Yes No
Current grant under review?
Pending grant application (K12, KL2, K23 or other)
Telephone (campus):
US Citizen: Yes No
Yes (type ___________ ) No
Yes (type: ____________) No
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Application for 2009-11
Clinical Research Curriculum
Personal Statement: Please describe (single spaced pages)
a) Previous education, training and experience in preparation for research (1 page),
b) Research interests, current mentors, and an initial research project planned (2 pages), and
c) Your 2-5 year career goals (1/2 page)
Please attach to this application:
1) Applicant CV
2) Applicant NIH biosketch
3) Mentor NIH biosketch
4) Signed candidate/mentor agreement (page 4 of this application).
Applications for 2009-10 accepted through April 30, 2009. Complete applications include all of the information requested in the pages above including the signed candidate/mentor agreement.
Note: If you are a scholar in a K12 or KL2 program, you may substitute that application for the personal statement (a-c above) and any of #1-4 under attachments that were part of the k12 application.
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Application for 2009-11
Clinical Research Curriculum
Having mentors from more than one discipline (”team mentoring”) is a critical element that allows researchers in training to become leaders and independent clinical researchers. Mentors should serve as advisors, experiential teachers and career role models.
1. Mentors have primary responsibility for guiding the Scholar toward research independence, by providing the applicant with the scientific and methodological expertise for their research project.
2. Mentors agree to help the applicant develop both hypotheses and research protocols; provide initial "peer review"; and assist with grant preparation and the development of effective presentations and publications.
3. Regular and frequent meetings are essential for success. Mentors agree to routine meetings to advise and support the applicant’s work.
4. Mentors will attend meetings, classes and seminars at which the applicant is presenting
5. Mentors will agree to provide one in-person peer review for one other trainee in EPID 896 or 805-606; a commitment of approximately 5 hours during 1 year.
6. Mentors will agree to identify a nother content expert for their mentee’s final mock review for EPID 806.
7. We agree to enter into a mentoring relationship. We will have regularly scheduled meetings ______ times per month.
The applicant has _____% protected time for research and research training activities. This time is funded using the following source(s) ______________________________________________________________
___________________________ (M entor’s signature)
___________________________ (Mentor’s signature)
___________________________ (Applicant’s signature) date____/____/____ date____/____/____ date____/____/____
APPLICANT AGREEMENT
I understand and agree to attendance and full participation in any of the K30 courses for which I am enrolled whether being taken for graduate credit or audit.
___________________________ (Applicant’s signature) date___/____/____
As the applicant’s Program Director, I agree to :
1. Guarantee financial support for _____ years.
2. Protected research time of at least 70% for the applicant including ability to attend scheduled courses.
3. Office space and equipment sufficient for research goals.
__________________________ (Program Director’s signature) date____/___/____
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