*TL1 Program Application for 2015 Awards (start date 9/1/2015)
Mentored Pre-doctoral Research Training Program
revised Dec. 2014
Application Checklist:
_____ Apply to either program: Clinical Investigation PhD or PhD minor
(refer to https://ictr.wisc.edu/GraduateProgram and direct questions to Sally Wedde, Education
Programs Administrator, at sewedde@wisc.edu or 262-3768)
_____ Secure a committed Mentor with an appropriate Clinical or Translational Project
_____ Student and Mentor complete the attached TL1 Program Application Form
_____ Submit a current CurriculumVitae for Student and Mentor
_____ Draft a Proposed Coursework Plan. Successful applicants (TL1 trainees) must fulfill the
full-time graduate student requirement for the TL1 program. That is 8 credits Fall, 8 credits
Spring, and 2 credits Summer.
_____ Student and Mentor obtain ICTR Membership
(refer to https://ictr.wisc.edu//)
For TL1 Applicants pursuing the Clinical Investigation PhD:
_____ Complete the Online Application to UW Graduate School
or
_____ MD/PhD Program Applicant: Submit a copy of your Medical Scientist Training
Program (MSTP) application
For TL1 Applicants pursuing the Clinical Investigation PhD Minor:
_____ Include a completed Intent to Complete a PhD Minor in Clinical Investigation
(refer to https://ictr.wisc.edu/files/MinorInClinicalInvestigationRequirements_GPCI_3.pdf)
*Application materials should be submitted electronically in a single pdf document, and program questions
directed to, Sally Wedde, TL1 Program Coordinator (sewedde@wisc.edu or 262-3768).
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*TL1
Program Application for September 1, 2015 Awards
I. Basic Data
Complete all questions in the Basic Data section. If a question is not applicable, please indicate so with the
words “Not Applicable”.
Name (Last, First, MI)
Degree/s
Birthdate (mm/dd/yyyy)
Current Position
Department
Address
City/State/Zip
Telephone (w/ area code)
Email address
Mentor’s Name & E-mail
Citizenship (select one):
U.S. Citizen
Permanent Resident of the U.S.
II. Information Required by the NIH
What is your gender?
Are you Hispanic?
Female
Yes
Male
No
What is your racial background?
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Asian
Black or African American
White (non-Hispanic)
Do you have a disability?
Yes
No
Do Not Wish to Provide
If yes, which of the following categories describe your disability (ies):
Hearing
Visual
Mobility/Orthopedic Impairment
Are you from a disadvantaged background?
Yes
No
Other?
Do Not Wish to Provide
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III. TL1 Applicant Section
1. Will you pursue the Clinical Investigation PhD, or PhD Minor?
2.
Are you requesting 1 or 2 years on this award?
Include the following detailed information to describe why you are a strong candidate for the TL1
Program (up to 2 pages):
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Previous Research Experience and Training
Research Interests
1. What clinical and translational research project(s) will you work on among the
projects in the lab? Describe the work you most enjoy.
2. How does your work in the lab relate to your mentor’s research goals? Are you able
to adjust your lab schedule to accommodate your coursework?
Career Goals
Your Mentor’s role in helping you to reach your research and career goals
1. Will you be encouraged to publish? What role will you have in publishing?
2. Will you be encouraged to attend conferences? Present posters?
3. What is the best training outcome from your perspective? From your mentors
perspective?
How the TL1 Program will benefit your research interests and career goals
Describe your level of need for the TL1 funding.
3. List (if any) your publications, abstracts, or manuscripts, including those in preparation (if
applicable).
I hereby certify that the information presented in this application is true and accurate. I have not knowingly
withheld any facts or circumstances that could interfere with the integrity and accuracy of this application.
If awarded a TL1 appointment, I will acknowledge the ICTR/NIH grant (UL1TR000427) on all work while
funded and on all future work that is a result of the work I completed while funded.
______________________________________________________________________________________
Applicant Signature
Date
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IV. TL1 Mentor Section
Proposed Mentor: _______________________________
Degree/s ____________________
Title: _______________________
Department: __________________________
Telephone: _____________
Email: __________________________
Statement Including the Following To Be Completed by Proposed TL1 Mentor:
1. Mentor’s research focus (1 paragraph):
2. Mentor’s prior experience with trainees (1 paragraph):
3. Describe the research training plan for this applicant (please be specific):
If this student is awarded a TL1 appointment, I will acknowledge the NIH ICTR and ICTR/TL1 grants
(UL1TR000427 and UL1TR000429) on all work that this student contributes to while funded, as well as all
future work that is a result of the work the student contributed to while funded on the TL1.
______________________________________________________________________________________
Mentor Signature
Date
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