University of Pittsburgh Emergency Medicine K12 Research Training Program

Application for 2012

Instructions:

·  Applications and letters of recommendation must be received by December 1, 2012. Depending on applications and available positions, we may announce later dates for additional applications.

·  Your application will be complete when we have the following:

1.  Complete application form

2.  Curriculum vitae

3.  Personal Statement

4.  Three Letters of Recommendation

Mailing Address:

Clifton W. Callaway, MD, PhD

University of Pittsburgh

Department of Emergency Medicine

Iroquois 400A

3600 Forbes Avenue

Pittsburgh, PA 15260

PERSONAL INFORMATION
Last Name: / First Name: / Middle:
Address:
City: / State: / Zip:
Country:
EMAIL: / Phone:

EDUCATION

UNDERGRADUATE:
School
Address
Degree
Dates of Attendance
Field of Study
GRADUATE:
School
Address
Degree
Dates of Attendance
Field of Study
MEDICAL SCHOOL:
School
Address
Degree
Dates of Attendance
Field of Study
OTHER:
School
Address
Degree
Dates of Attendance
Field of Study

POST GRADUATE EDUCATION (Please include complete address)

RESIDENCY TRAINING:

Specialty
Hospital
Program Director
Address
Phone Number
Dates of Training

FELLOWSHIP TRAINING (If Applicable):

Specialty
Hospital
Program Director
Address
Phone Number
Dates of Training

OTHER TRAINING/EXPERIENCE:

Specialty or Field
Hospital /Institution
Program Director
Address
Phone Number
Dates of Training

DEMOGRAPHIC INFORMATION: This information is for NIH Reporting purposes.

Date of Birth
Gender:
US Permanent Resident or Citizen
Race / Ethnicity (Check all that apply: / American Indian or Alaska Native / Asian / Native Hawaiian or Pacific Islander / Hispanic
Black or African American / White / Non-Hispanic

REFERENCES: Please list the full name, telephone number and email address of three individuals who will provide letters of recommendation. One letter should be from your current program director. Letters should be sent to Dr. Yealy or Dr. Callaway at the address below.

Name:
Institution:
Email / Telephone:
Name:
Institution:
Email / Telephone:
Name:
Institution:
Email / Telephone:

Clifton W. Callaway, MD, PhD

University of Pittsburgh

Department of Emergency Medicine

Iroquois 400A

3600 Forbes Avenue

Pittsburgh, PA 15260

Phone 412-647-3078

FAX 412-647-6999

PLEASE PASTE A COPY OF YOUR PERSONAL STATEMENT HERE OR SEND TO US VIA EMAIL.

Describe your interest in an investigative career. Indicate how the K12 program will facilitate your progress towards independent investigators. We are particularly interested in the topics or areas where you would like to do research. It is not necessary to describe specific aims or projects, but you can speculate about the scope or focus of career training grants or project grants that you might pursue.