UT Southwestern Center for Translational Medicine (CTSA)
2014 Clinical and Translational Research Scholar Program Application
COMPLETE APPLICATION DUE BY EMAIL TO Amy.Mackenroth@UTSouthwestern.edu: FEBRUARY 28, 2014
We also request an informal email declaring intent to apply by January 31, 2014
We will accept only completed applications (typed) with all components listed on the application. Please submit your completed
application no later than the date listed above.
Application Requirements:
-Completed general application (this document)
-Curriculum Vitae: submit a copy of your current CV with the application, using the standardized UT Southwestern
Promotion & Tenure format, which can be found on this shared drive: W:\PUB\SMSDEAN\Promotion & Tenure or by
requesting it of us via email. Please make sure to include grant support, publications, and any teaching experience.
-A career development plan (1000 words or less; should be single-spaced, .5 inch margins, 11 point Calibri font): Include
current area(s) of research interest, current areas of clinical/translational investigation, a proposed training plan including
information about additional training, what you hope to gain from the mentor experience, what courses you think will be
the most beneficial to your success, and career goals.
-A personal statement answering the following questions (500 words or less; should be single-spaced, .5 inch margins, 11
point Calibri font):
1. How did you arrive at this place in your career?
2. A career in clinical/translational research is challenging, with many opportunities and frustrations. Why are you attracted
to this career?
-A description of a potential research project you would like to work on or are thinking about (500 words or less; should be
single-spaced, .5 inch margins, 11 point Calibri font)
-A letter of support and commitment from your Department Chair, guaranteeing 75% protected time for two years. This is
the only item required to be sent via mail to campus mail code 8592 in a signed, sealed envelope. More details are available
on page 5 of this application.
-One professional letter of reference, not including the letter from your Department Chair or Mentor(s)
-One letter of support and commitment from your Scientific Mentor (an additional letter from a career/humanistic mentor
will be accepted, but is not required)
-A separate, formal online application to the Graduate Certificate Program in Clinical Science at UT Southwestern Graduate
School of Biomedical Sciences.
Submit Clinical and Translational Research Scholar Program application, CV, essays, and letters of recommendation via email to the
address listed at the top of the application.
Contact Information for Questions:
Amy Mackenroth, M.A.
Program Administrator
Education & Career Development
Phone: 214.648.2752
5323 Harry Hines Blvd., B3.302, Dallas, TX 75390-8592
Website: http://www.utsouthwestern.edu/research/translationalmedicine/index.html
Application Timeline:
Call for applications issued: January 2013
Informal, emailed letter of intent to apply requested by:
January 31, 2014
Application due: February 28, 2014
Interviews/Scholar selection process: March 6, 2014 - 5-9pm
Announcement of candidates selected: April 1, 2014
Mandatory orientation: TBD
Appointment start date: July 1, 2014
Program completion date: June 30, 2016
For questions, contact: Amy Mackenroth -- amy.mackenroth@utsouthwestern.edu or 214.648.2752
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UT Southwestern Center for Translational Medicine (CTSA)
2014 Clinical and Translational Research Scholar Program Application
Personal Information
Prefix:
Last Name:
Previous Last Name:
First Name:
Middle Name:
Suffix:
Gender:
Female
Date of Birth:
Race:
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
White
Ethnicity:
Hispanic/Latino
Citizenship:
US Citizen
Contact Information
Work Phone:
Home Phone:
Mobile Phone:
Pager:
Male
NIH eRA Commons Username:
If you need a username, click here.
UTSW Person #:
Not Hispanic or Latino
Multiple Races/Other:
Unknown/Do not want to report
Unknown/Do not want to report
Permanent Resident (verification of permanent residency required)
If applicable, alien registration receipt card:
I-151
I-155
Other:
Work Email Address:
Home Mailing Address:
Personal Email Address:
UTSW Mail Code:
Academic Institution Information
Current Academic Institution:
UT Southwestern Medical Center
Children’s Medical Center
Parkland Health and Hospital System
The US Department of Veterans Affairs North Texas Health Care System
Texas A&M Health Science Center, Baylor College of Dentistry
Texas Tech Univ. Health Sciences Center, School of Pharmacy
The University of Texas at Austin School of Nursing
The University of Texas at Dallas School of Behavioral and Brain Health
The University of Texas at Houston School of Public Health, Dallas Regional Campus
Other:
Department/Division:
Current Title:
Current Academic Rank:
Post-Doctoral Fellow
Instructor
Assistant Professor
Associate Professor
Current Track:
Clinical Scholar Track
Tenure Track
Research Track
Clinician Track
Tenured
Other:
# of Years at Institution:
Statement of Intent
Are you committed to a career as a clinical/translational scientist:
Yes
No
If selected, do you agree to enter the program for 2 years and devote 75% of your time to completion:
For questions, contact: Amy Mackenroth -- amy.mackenroth@utsouthwestern.edu or 214.648.2752
Page 2
Yes
No
UT Southwestern Center for Translational Medicine (CTSA)
2014 Clinical and Translational Research Scholar Program Application
Education
Post-secondary; for foreign degrees, please list the US equivalent.
Institution:
Location:
Degree:
Major/Minor Field:
Graduation Date:
Institution:
Location:
Degree:
Major/Minor Field:
Graduation Date:
Institution:
Location:
Degree:
Major/Minor Field:
Graduation Date:
Institution:
Location:
Degree:
Major/Minor Field:
Graduation Date:
Other Academic Qualifications
Post-graduate training, residencies, fellowships, certificates, awards, etc.
Institution:
Location:
Type of Training and Specialty:
Dates of Training:
Institution:
Location:
Type of Training and Specialty:
Dates of Training:
Institution:
Location:
Type of Training and Specialty:
Dates of Training:
Institution:
Location:
Type of Training and Specialty:
Dates of Training:
Name(s) of Specialty Board(s)
If applicable
Medical Subspecialties
If applicable
Board 1:
Board 2:
Board 3:
Board 4:
Subspecialty 1:
Subspecialty 2:
Subspecialty 3:
Subspecialty 4:
# of Years Since Residency:
State of Medical Licensure:
Total # of Peer Reviewed Publications:
Total # of First-Authored Peer Reviewed Publications:
Total # of Peer Published Abstracts:
For questions, contact: Amy Mackenroth -- amy.mackenroth@utsouthwestern.edu or 214.648.2752
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UT Southwestern Center for Translational Medicine (CTSA)
2014 Clinical and Translational Research Scholar Program Application
Research Experience & Mentors
Are you currently involved in clinical/translational research?
If yes, please discuss in the career development essay.
Yes
Have you identified a Scientific/Research Mentor?
If not, it will not exclude you from consideration.
Yes
No
Have you identified a Career/Humanistic Mentor?
If not, it will not exclude you from consideration.
Yes
No
No
For information about expectations and mentor guidelines, please see page 6. A letter of support from your scientific mentor is
required and is separate from your references.
Scientific Mentor
Name:
Department/Division:
Email Address:
# of Years Known:
UTSW Person #:
Career Mentor
Name:
Department/Division:
Email Address:
# of Years Known:
UTSW Person #:
Other Mentor (if applicable)
Name:
Department/Division:
Email Address:
# of Years Known:
UTSW Person #:
Funding
Do you currently have financial support for your research?
Yes
No
If yes, please send an “NIH Other Support” document outlining all current research support.
Have you been or are you currently funded (partially or fully) by a T32, F32, R01, R21, P01, P50, P60, U54, K, or equivalent?
Yes
No
If yes, please specify:
Are you funded by any institution/organization that precludes you from receiving federal training grant support?
Yes
No
If yes, please specify:
For questions, contact: Amy Mackenroth -- amy.mackenroth@utsouthwestern.edu or 214.648.2752
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UT Southwestern Center for Translational Medicine (CTSA)
2014 Clinical and Translational Research Scholar Program Application
Previous and Current Grant Support (if applicable)
Send a list if you have more than three entries.
Application Date:
Title of Grant & Agency:
Type of Grant:
Role:
Grant #:
Grant Period:
Award Amount:
Application Date:
Title of Grant & Agency:
Type of Grant:
Role:
Grant #:
Grant Period:
Award Amount:
Application Date:
Title of Grant & Agency:
Type of Grant:
Role:
Grant #:
Grant Period:
Award Amount:
References
Submit one letter of reference from a person who can testify to your professional qualifications. Your Department Chair and
Mentors should not be included on this list.
Name:
Department/Division:
Email Address:
# of Years Known:
Department Chair Letter of Support
All candidates must submit a detailed letter of support from his/her Department Chair, describing the Chair’s opinion of the
candidate’s talents, energy, and potential. The letter should also indicate the candidate’s role in the department during the
Program. The letter should make clear that the Chair will provide 75% protected time for 2 years, and funding for the candidate’s
salary and fringes during this time. The Chair should also guarantee a faculty appointment following satisfactory completion of the
program.
The letter should be addressed to:
Robert D. Toto, MD
Associate Dean for Clinical and Translational Research
By checking here, you acknowledge that you have spoken
with your Department Chair and made him/her aware of this
requirement and have already requested for a letter of
support to be submitted by 2/28/2014, to which he/she
agreed.
The letter should be mailed or hand delivered to:
Amy Mackenroth, MA
Education & Career Development Program Administrator
5323 Harry Hines Boulevard (B3.302), Dallas, TX 75390-8592
For questions, contact: Amy Mackenroth -- amy.mackenroth@utsouthwestern.edu or 214.648.2752
Page 5
UT Southwestern Center for Translational Medicine (CTSA)
2014 Clinical and Translational Research Scholar Program Application
Mentor Agreement & Guidelines
Effective mentorship is a critical element in the process by which mentees achieve excellence in the design and management of
clinical research, facilitating their growth as leaders in clinical and translational science. By the end of the first semester, the mentee
must identify both a scientific and career/humanistic mentors. Being a mentor is a responsibility and a privilege, as it enables one to
work with the best and brightest of the next generation. Together, the mentee and mentors will form a relationship focused on
mentee career development as a clinical/translational researcher.
Expectations of Scientific Mentors
 Primary responsibility for guiding mentees toward research independence. Together with the mentee, the scientific mentor will
help identify investigators to serve on the mentoring team. The scientific mentor will provide the mentee with the scientific and
methodological expertise for their research projects.
 Clearly delineate specific expectations of the substantive learning/research skills to be achieved.
 Primary responsibility for helping the mentee develop both hypotheses and research protocols; providing the initial "peer
review" that helps validate the scientific merit of all proposals; helping the mentee to obtain appropriate interdisciplinary
consultations; assisting with all phases of grant preparation; and the development of effective presentations and publications.
 Overseeing and approving all required practicum
a. Research Project: Mentor must submit a “mentor approval form” summarizing the mentee’s role on the project.
b. Manuscript Suitable for Publication: Mentor must submit a “mentor approval form” and include information about 1)
his/her review and approval, and 2) manuscript’s submission status and the journals to which it was/will be submitted.
c. Extramural Research Grant Application (K23 or equivalent): Mentor must submit a “mentor approval form” discussing
his/her judgment as to the scientific merit of the application.
Expectations of Career/Humanistic Mentors
 Develop with the mentee specific milestones and timelines for achieving career development goals; help mentee to develop
his/her career identity.
 Assist mentee in navigating the culture of academic medicine.
 Encourage mentee to expand his/her professional network.
 Mentee/mentor can set expectations that meet their specific needs associated with “life” issues, concerns, and celebrations;
provide guidance with particular issues specific to gender, race, etc.
Expectations of ALL Mentors & Mentee
 The mentee is ultimately responsible for initiating and maintaining the relationship with the mentor(s). The mentee has the
right to change mentors if his/her research question changes and/or the mentoring relationships are not meeting expectations.
 Although the idea of team mentoring is good, the mentoring relationship should be ultimately handled solely by the immediate
mentor and mentee (not delegated).
 A standard expectation is that mentors will develop a relationship with their mentee, be available/accessible, be an advocate,
and be resourceful.
 Regular and frequent meetings are essential for success. Thus, the mentee should have regular meetings with at least one
member of the mentoring team, in addition to meeting with the entire mentoring group at least once per quarter. The mentee
should prepare a brief formal summary of meetings with the entire mentoring team.
 The mentee will request that his/her mentors attend seminars at which the mentee is presenting. Attendance is highly
encouraged as well as an important aspect of the development and growth of all mentees seeking a career in clinical research.
 Mentors and the mentee should participate in (a) the Clinical Scholars retreats; (b) evaluations and assessments of the
individual mentee and team mentoring relationships; and (c) intimate involvement in the execution of the mentee’s practicum
for the program.
 The mentee is required to meet every six months with the Center for Translational Medicine, Education & Career Development
team members to assess the overall mentoring experience; mentors & mentees will have an open line of communication with
Keith Argenbright, MD, MAA (Mentorship, Leadership, and Career Development Director) and Amy Mackenroth, MA (Program
Administrator).
For questions, contact: Amy Mackenroth -- amy.mackenroth@utsouthwestern.edu or 214.648.2752
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