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CAPS Program: Application
Instructions
Important things to consider in preparing your application:
a) express a clear career vision that is your own idea; b) identify supportive colleagues and
collaborators; and c) see this process leading to an RO1 submission.
1. Submit an electronic version of the application in one Microsoft Word file (no pdf) to
anderson@epi.umn.edu. Place biosketches after each appropriate person's section.
2. Send an exact hard copy with signatures to Russell V. Luepker, MD, Division of
Epidemiology and Community Health, 1300 S. 2nd St., 300 WBOB, Minneapolis, MN 55454-
1015.
3. Adhere to each section's page limits. Applications that exceed maximum page limits will be
returned to applicants for revision.
4. A 1-2 page list of literature references may be included with your application packet. No
additional documents (i.e. letters of support) will be reviewed.
5. Submit documents in Arial 11 with 1/2-inch margins. The fields in the application will expand
as text is entered. Do not alter the application format in any way or it will be returned for
revision.
6. Co-mentor option:
If you have selected a mentor who does not have a strong record of successful trainees and/or
NIH funding, it is advisable to identify another mentor with a strong record of trainees and NIH
funding and include both on your mentoring team as co-mentors (either co-senior mentors or
co-associate mentors). Define the roles of each mentor as appropriate to your career plan.
7. Biostatistician mentor option:
It is not necessary to name your biostatistician mentor before submitting your
application forms to CAPS. You may indicate that your biostatistician mentor is
"to be determined". If you are selected as a CAPS scholar, you will need to
consult with James Neaton, PhD, MS, Program Co-Director, to identify a biostatistician
mentor. You will need to complete a mentor form for a biostatistician mentor before
your application can be submitted to the NIH for final approval.
8. Make sure that the CAPS start date that you propose does not conflict with other NIH
support.
9. If you submitted an application previously, please include a 1/2-page introduction to your
resubmission that states what you have done to address the MAC review committee’s
concerns.
CAPS Program: Application
DEPARTMENT/DIVISION HEAD STATEMENT
Scholar name:
Department/Division Head Name:
Title:
School:
Department:
Division:
Proposed Mentoring Team
(add numbers as needed to list all proposed mentors
and Co-Senior or Co-Associate to titles as appropriate)
1. Senior Mentor Name:
2. Associate Mentor Name:
3. Associate Mentor Name (Statistician):
1. Describe your evaluation of this scholar's background and potential for a successful academic
clinical research career (1/2 page, single-spaced).
2. Describe how this scholar will become integrated in the research/teaching/clinical service of the
unit. Describe the scholar’s proposed non-K12 activities (≤ 1/2 page, single-spaced).
In making this application, I understand that the position must either be a faculty member or a senior fellow on
a track to become faculty if performance is acceptable. Protected time for research, study, and participation in
K12 activities at 75% will be available for the duration of the K12 clinical scholar award (50% for surgical
scholars).
_______________________________
Signature of Department/Division Head Type Name of Department/Division Head
________________________________
Signature of Dean Type Name of Dean
CAPS Program: Application
SCHOLAR FORM
Name:
Date of application:
Department:
Degree:
Academic Rank:
Number of years out of training:
Date of Birth:
Race/Ethnicity:
1. Describe your background, clinical research experience, and specific area of research interest.
Include what you hope to contribute to your academic and clinical fields in the next 10 years and
how the scholar development program will help you develop your career in multidisciplinary
clinical research (1-2 pages, single-spaced).
2. Describe a 3-year career development plan with a timeline and objectives that will advance your
career goals. Present a systematic plan to obtain the necessary educational background, research
experiences and skills, and mentoring necessary to launch an independent career in clinical
research. (1-3 pages, single-spaced)
- Under educational background, indicate how your proposed clinical research training will fit
into your career plan.
- Under research experiences, state your hypothesis and title your research plan, describe your
research theme and the studies you propose to pursue, including 1-2 paragraphs describing
your overall research theme and proposed projects in the context of the literature.
- Under mentoring, describe what you intend to learn from each proposed mentor as well as how
the mentors will interact with you as a team.
3. Attach an NIH biosketch (include all funding sources; list all grants you're on and your specific
role on each grant).
4. Attach a completed PHS 2271 form.
NOTE: Do NOT complete this form unless instructed to do so following MAC review of your
application.
_______________________________
Signature
CAPS Program: Application
SENIOR MENTOR FORM
Scholar name:
Senior mentor name:
Title:
School:
Department:
Division:
1. Describe your evaluation of this scholar's background and potential for a successful academic
clinical research career. (1/2 page, single-spaced)
2. Describe the intended long-term career path you envision for this clinical scholar. (≤ 1/2 page,
single-spaced)
3. Describe a 3-year timeline with specific mileposts for the clinical scholar's development in
education, research, and networking.
4. Describe the nature, frequency and extent of interaction planned between you and the clinical
scholar during the award period (≤ 1/2 page, single-spaced).
5. How will you integrate the rest of the mentoring team to support the career development of the
clinical scholar? (≤ 1/2 page, single-spaced).
6. Attach an NIH biosketch (include a list of current funded research).
Complete items 7-8 if you have not been NIH-approved as a K12 Senior Mentor.
I am an NIH approved senior mentor
Check mentor list on CAPS website: www.epi.umn.edu/caps/mentors.shtm
7. Provide a description of your past research experience and current research focus (include
current and past grant funding) (1 page, single-spaced).
8. Provide a list of 5-10 trainees you have advised in the past 10 years in chronological order
beginning with the most recent (include name of trainees, training period, institution, and types of
training).
Current NIH
Name of Funding -
School Department Area of Expertise
MENTOR List NIH grant
numbers
Current or Last
Name of
Title of Research Known Research
TRAINEEa Training Current or Last
Degree Sought Project While Training Topic AND
(Status while in Period Known Position
With This Mentor List NIH grant
Training)
numbers
a
Please list trainees/mentees chronologically in decreasing order based on the end dates of their
appointments.
_______________________________
Signature
CAPS Program: Application
ASSOCIATE MENTOR FORM
Scholar name:
Associate mentor name:
Title:
School:
Department:
Division:
1. Describe the nature and extent of interaction planned between you and the clinical scholar during
the proposed award period (≤ 1/2 page, single-spaced).
2. How will you integrate your efforts to support the career development of the clinical scholar with
the rest of the mentoring team? (≤ 1/2 page, single-spaced)
3. Attach an NIH biosketch (include a list of current funded research).
Complete items 4-5 if you have not been NIH-approved as a K12 Mentor.
I am an NIH approved senior/associate mentor
Check mentor list on CAPS website: www.epi.umn.edu/caps/mentors.shtm
4. Provide a description of your past research experience and current research focus (describe
current and past grant funding) (1 page, single-spaced).
5. Provide a list of 5-10 trainees (postdoctoral students and junior faculty) you have advised in the
past 10 years in chronological order beginning with the most recent (include name of trainees,
training period, institution, and types of training).
Current NIH
Name of Funding -
School Department Area of Expertise
MENTOR List NIH grant
numbers
Current or Last
Name of
Title of Research Known Research
TRAINEEa Training Current or Last
Degree Sought Project While Training Topic AND
(Status while in Period Known Position
With This Mentor List NIH grant
Training)
numbers
a
Please list trainees/mentees chronologically in decreasing order based on the end dates of their
appointments.
_______________________________
Signature
CAPS Program: Application
ASSOCIATE MENTOR FORM
Scholar name:
Associate mentor name:
Title:
School:
Department:
Division:
1. Describe the nature and extent of interaction planned between you and the clinical scholar during
the proposed award period (≤ 1/2 page, single-spaced).
2. How will you integrate your efforts to support the career development of the clinical scholar with
the rest of the mentoring team? (≤ 1/2 page, single-spaced)
3. Attach an NIH biosketch (include a list of current funded research).
Complete items 4-5 if you have not been NIH-approved as a K12 Mentor.
I am an NIH approved senior/associate mentor
Check mentor list on CAPS website: www.epi.umn.edu/caps/mentors.shtm
4. Provide a description of your past research experience and current research focus (describe
current and past grant funding) (1 page, single-spaced).
5. Provide a list of 5-10 trainees (postdoctoral students and junior faculty) you have advised in the
past 10 years in chronological order beginning with the most recent (include name of trainees,
training period, institution, and types of training).
Current NIH
Name of Funding -
School Department Area of Expertise
MENTOR List NIH grant
numbers
Current or Last
Name of
Title of Research Known Research
TRAINEEa Training Current or Last
Degree Sought Project While Training Topic AND
(Status while in Period Known Position
With This Mentor List NIH grant
Training)
numbers
a
Please list trainees/mentees chronologically in decreasing order based on the end dates of their
appointments.
_______________________________
Signature
CAPS Program: Application
ASSOCIATE MENTOR FORM
Scholar name:
Associate mentor name:
Title:
School:
Department:
Division:
1. Describe the nature and extent of interaction planned between you and the clinical scholar during
the proposed award period (≤ 1/2 page, single-spaced).
2. How will you integrate your efforts to support the career development of the clinical scholar with
the rest of the mentoring team? (≤ 1/2 page, single-spaced)
3. Attach an NIH biosketch (include a list of current funded research).
Complete items 4-5 if you have not been NIH-approved as a K12 Mentor.
I am an NIH approved senior/associate mentor
Check mentor list on CAPS website: www.epi.umn.edu/caps/mentors.shtm
4. Provide a description of your past research experience and current research focus (describe
current and past grant funding) (1 page, single-spaced).
5. Provide a list of 5-10 trainees (postdoctoral students and junior faculty) you have advised in the
past 10 years in chronological order beginning with the most recent (include name of trainees,
training period, institution, and types of training).
Current NIH
Name of Funding -
School Department Area of Expertise
MENTOR List NIH grant
numbers
Current or Last
Name of
Title of Research Known Research
TRAINEEa Training Current or Last
Degree Sought Project While Training Topic AND
(Status while in Period Known Position
With This Mentor List NIH grant
Training)
numbers
a
Please list trainees/mentees chronologically in decreasing order based on the end dates of their
appointments.
_______________________________
Signature
CAPS Program: Application
ASSOCIATE MENTOR FORM
Scholar name:
Associate mentor name:
Title:
School:
Department:
Division:
1. Describe the nature and extent of interaction planned between you and the clinical scholar during
the proposed award period (≤ 1/2 page, single-spaced).
2. How will you integrate your efforts to support the career development of the clinical scholar with
the rest of the mentoring team? (≤ 1/2 page, single-spaced)
3. Attach an NIH biosketch (include a list of current funded research).
Complete items 4-5 if you have not been NIH-approved as a K12 Mentor.
I am an NIH approved senior/associate mentor
Check mentor list on CAPS website: www.epi.umn.edu/caps/mentors.shtm
4. Provide a description of your past research experience and current research focus (describe
current and past grant funding) (1 page, single-spaced).
5. Provide a list of 5-10 trainees (postdoctoral students and junior faculty) you have advised in the
past 10 years in chronological order beginning with the most recent (include name of trainees,
training period, institution, and types of training).
Current NIH
Name of Funding -
School Department Area of Expertise
MENTOR List NIH grant
numbers
Current or Last
Name of
Title of Research Known Research
TRAINEEa Training Current or Last
Degree Sought Project While Training Topic AND
(Status while in Period Known Position
With This Mentor List NIH grant
Training)
numbers
a
Please list trainees/mentees chronologically in decreasing order based on the end dates of their
appointments.
_______________________________
Signature
