Introduction to Clinical Research Application

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					                                                                                     In partnership with




         Introduction to Clinical Research Application
                       September 10 from 8:15a.m. – 3:30p.m.
                       September 11 from 8:15a.m. – 4:00p.m.

1. Name: __________________________                   5. Department:______________________

2. Phone:___________________________                  6. Division:_________________________

3. BWH ID Number: _________________                   7. Position:_________________________

4. E-mail: __________________________                 8. BWH Title:_______________________

9. Academic rank or position at BWH:
              Faculty:
              Fellow, please indicate year:
              Resident, please indicate year:
              Other:

10. Mentors:

11. Do you have any experience conducting clinical research?
               No                              Yes, please describe:

12. Have you ever written your own research study or grant proposal application?
               No                              Yes, please describe:

13. Do you plan on submitting a study protocol or grant application next year?
               No                               Yes, please describe:

14. Would you to like to receive individual consultation from a senior investigator about a
    research idea of yours?
                No                              Yes, please describe:
                                                Use additional sheets if necessary

15. By registering for the Introduction to Clinical Research course, I agree to participate in both
    days and all sections of the training. Signature:

16. Date:

Please return by August 12, 2009 to:
Lisa Horton                                                        lhorton1@partners.org
Center for Clinical Investigation                                  PH: 617-525-7654
One Brigham Circle, 3rd Floor                                      FAX: 617-525-7752