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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

				
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