CRISMA research fellowship application
Contact Information and demographics:
Name
Last
First
Current mailing address
Street
City
State/Province
Country
Zip code
Permanent mailing address (if different from above)
Street
City
State/Province
Country
Zip code
Telephone - Please indicate preferred phone number
Dayime
telephone
Evening
telephone
Email
Primary email
Secondary email
Demographics
Birth date
(day/month/year)
Citizenship
Country of residence
Marital status
Children?
Middle initial
Education and work history: (add rows as necessary for additional education/work history)
University or other undergraduate education
Institution
Location
Dates attended
Degree
Institution
Location
Dates attended
Degree
Medical or graduate school
Institution
Location
Dates attended
Degree
Institution
Location
Dates attended
Degree
Internships, Residencies and Fellowships (clinical or research) or other postgraduate
education
Institution
Location
Type of training
(research or clinical and
specialty/subspecialty)
Dates attended
Degree received
Institution:
Location:
Type of training
(research or clinical and
specialty/subspecialty)
Dates attended:
Degree received:
Institution:
Location:
Type of training
(research or clinical and
specialty/subspecialty)
Dates attended:
Degree received:
Work history
Name of company
or institution:
Position:
Dates worked:
Brief description
(clinical, research or other)
Name of company
or institution:
Position:
Dates worked:
Brief description
(clinical, research or other)
Name of company
or institution:
Position:
Dates worked:
Brief description
(clinical, research or other)
Publications, honors/awards, references
Honors and awards:
Original research publications (please underline name in author list, add additional
lines/pages if necessary):
Invited reviews or book chapters:
Standardized test scores (if available):
TOEFL (REQUIRED – minimum 80):
USMLE Step 1 ______________ Step2 _______________ Step 3 ________________
GRE: _____________________________
Recommenders – Please ask recommenders to prepare a brief letter supporting your potential for a
career in research
Reference 1
Name:
Title:
Institution:
Telephone:
Reference 2
Name:
Title:
Institution:
Telephone:
Reference 3
Name:
Title:
Institution:
Telephone:
Proposed start date, area of focus, and duration of study at the University of
Pittsburgh
Proposed start date:
Please rank the following research areas 1-4 in order of your preferred focus, one being
most preferred
Basic science (laboratory discovery of mechanisms of disease)
Clinical (epidemiology, outcomes and effectiveness etc.)
Translational (bench to bedside, clinical trials of new therapies)
Computer modeling
Proposed duration of fellowship:
If proposed duration of study is less than 2 years, please describe background qualifications that you
believe would enable you to complete a project and educational program within the proposed
timeframe
Personal statement: In 250 words or less please briefly describe your background, current
activities, research interests (if known), and career objectives.
Required items checklist – applications will not be reviewed until all materials are
received
1. Completed application form, including
a. Personal statement briefly (250 words or less) describing background, goals and
research interest
b. TOEFL score (required), minimum score of 80 unless given specific exception by
program director
c. Other standardized examination scores (USMLE or GRE test results)
2. Three letters of recommendation
Thank you for your interest in the CRISMA translational research training fellowship, we look forward
to reviewing your application!