"Introduction to Clinical Research Application"
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 firstname.lastname@example.org Center for Clinical Investigation PH: 617-525-7654 One Brigham Circle, 3rd Floor FAX: 617-525-7752