Capstone Certificate Application

Certificate in Fundamentals of Clinical Research

Students who are applying for a Capstone Certificate (available to those who hold a Bachelor’s degree and are not currently enrolled as graduate students or health professional students) must also apply for special student status at https://continuingstudies.wisc.edu/advising/advising/applycapstone.htm

Date:
(Month/Day/Year) / Student ID#
Name:
(Last, First, Middle Initial) / Email address:
Mailing Address:
(Street/City/State/Zip Code)
Phone number: / U.S. Veteran:
Yes
No
Place of Birth:
(City, State, Country) / Citizenship:
U.S. Citizen
U.S. Permanent Resident
Non-U.S. Citizen
Country of Origin:
If currently in U.S., please indicate Visa type:
Ethnic Heritage (optional):
Black/African American (not Hispanic)
Cambodian Hmong Laotian or Vietnamese (admitted to U.S. after 12/31/75) / Other Asian/Pacific Islander
American Indian or Alaskan Native
Mexican-American/Chicano/a Puerto Rican / Other Hispanic
White (not Hispanic)
Other (please specify)
Degrees earned/expected, institutions, dates attended. Do not state “See resume.”

Please attach your biosketch, resume or CV. (https://ictr.wisc.edu/CiteICTR)

Please attach your transcripts from after high school.

Please attach a Statement of Purpose, on which you explain the following:

1.  Why you wish to pursue a Capstone Certificate in the Fundamentals of Clinical Research? How do you plan to use the knowledge?

2.  Your specific research interest(s).

Any mentors/advisors or potential mentors/advisors with whom you would like to work.

INTENT TO ENROLL

I plan to enroll in the Certificate in the Fundamentals of Clinical Research beginning the following term:

Spring 2016 Summer 2016 Fall 2016 Spring 2017 Summer 2017 Fall 2017

I plan to complete the program in: 1 year 2 years 3 years

Course Plan: I plan to take the following courses (indicate course number/title and semester/year):

I have already taken the following core course(s):

BMI 541 Ethics course (choice of 6)

BMI 542 BMI 544 Population Health 797

How did you hear about the Certificate Fundamentals of Clinical Research?

Is the certificate required as part of a training grant? Yes No

If Yes, grant name and number:

I currently have ICTR membership (required of all participants in ICTR certificate and graduate programs. https://ictr.wisc.edu/ictrmember).

I have submitted an application to the UW-Madison Division of Continuing Studies.

I certify that the information in this application is true and complete to the best of my knowledge:

Name of Applicant (Please print.) Signature of Applicant Date

Please ask one advisor / letter of reference writer to submit a brief letter directly to the program.

Submit this application and supporting documents in one pdf (and separate letter of recommendation) to Sally Wedde, Education Programs Administrator:
/ OR / Deliver materials to Sally at 2112 Health Sciences Learning Center, 750 Highland Ave., Madison, University of Wisconsin Institute for Clinical & Translational Research

2112 Health Sciences Learning Center • 750 Highland Avenue • Madison, Wisconsin 53705 • 608-262-7657 •