2016 DFCM Call for Applications – Application Form

Clinician Scientist/Clinician Investigator/Research Scientist/New Investigator/Graduate Research Studies

Complete and return this form by January 2, 2017 along with an up-to-date annotated CV, letter of support from a Chief/Division Director/Director responsible for the matched funding, and 3 letters of reference to: Dr. Paul Krueger ()

Name:
Current academic appointment date of appointment:
Award applied for:
Proportion of protected time for research:
Current Research degrees:
List Career Awards:
Keywords/phrases to describe your research:
Please attach a 5 page description of your research plan for the next 5 years which includes: a detailed description of your research objectives and questions (max 3 pages); a 2 page description of how your research aligns with the University of Toronto Practice-Based Research Network (UTOPIAN); and a description of your research setting and proposed collaborators (max 1 page). In the space below, please provide a point form overview in 250 words or less.

Number, Type and Total Amounts of GRANTS:

Type of Grant / Currently Held / Held Last 5 Years (2012-2016)
Number / Amount / Number / Amount
Peer Reviewed Grants:
As Principal Investigator
As Co-Principal Investigator
As Co-Investigator
Other Grants:
As Principal Investigator
As Co-Principal Investigator
As Co-Investigator

Number and Type of PUBLICATIONS:

Type of Publication / Number of Publications
(including those in press)
Last 5 years (2012-2016) / Number Under Review
Peer Reviewed Journal Articles:
As Principal Author
As Senior Responsible Author
As Co-Author
Peer Reviewed Abstracts:
As Principal Author
As Senior Responsible Author
As Co-Author
Other Publications: (specify type and role)

Number and Type of PRESENTATIONS:

Type of Presentation / Number of Presentations and Role (PI or Co-I)
Last 5 years (2012-2016) / Accepted for 2016/2017
Peer Reviewed Presentations
International
National
Provincial
Local
Peer Reviewed Workshops
International
National
Provincial
Local
Peer Reviewed Posters
International
National
Provincial
Local
Non Peer Reviewed Presentations
(specify type and role e.g. invited, keynote)
International
National
Provincial
Local

International, National and Provincial Research Committees (last 5 years e.g. CIHR Review Committee):

Name of Committee / Role

Other Awards and Recognitions (last 5 years e.g. salary/training awards):

Type of Award / Describe Award(s)
Related to Research (specify)
Other Award (specify)

Other Activities (last 5 years)

Activities / Number
Formal Mentorship:
Faculty members
Masters students
PhD students
Others (specify)
Committee Membership (specify University, DFCM, Local Department)
Other (specify):

______

Chief / Division Director (Print Name) Signature Date

______

Applicant (Print Name) Signature Date

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