EPI 259: Grant Writing Workshop Spring 2015

EPI 259: Grant Writing Workshop
Spring 2015

Application Form

First Name: Last Name: Middle Initial:

Degree(s):

Office address:

UCSF Box Number:

Daytime phone #: ()- Fax #:()-

Email address:

Current position (eg, Resident, Fellow, Asst Prof):

Institution:

School (e.g., Medicine, Nursing, Pharmacy, Dentistry, etc):

Department (e.g. Medicine, Pediatrics, etc):

Division (e.g., Cardiology, Infectious Diseases) (if applicable):

Date of Birth:

Ethnicity: Gender:

Country of citizenship:

Program Director or Division Chief/Dept Chair:

Payment: Course fees covered by the Department of Epidemiology and Biostatistics.

Return to Olivia DeLeon by March 21, 2016: UCSF Campus Box 0560 OR Training in Clinical Research Program, UCSF Dept. of Epidemiology and Biostatics, 550 16th Street, 2nd floor, San Francisco, CA 94143.

Fax: (415) 514-8150 Phone: (415) 514-8231 Email:

Continue for Supplemental Questionnaire…

Supplemental Questionnaire for EPI 259 Advanced Grant Writing Workshop.

Please email this page to Judy Hahn at (Payment page should be sent to Olivia De Leon).

1.  Who is your proposed sponsor?

Name:

Division/Department:

2.  In a few sentences, briefly describe your research experience to date. This could be at UCSF or elsewhere.

3.  In a few sentences, briefly describe the topic of research that you will pursue in the training grant. If you have not identified a research topic please state this.