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Document Sample
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
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