APPLICATION FORM

To apply, please complete this form and click the submit button below. You will receive an email confirmation when we have received your application.

If you have questions or have difficulty submitting this application, please contact us at: owen.kim@cshs.org

* indicates a required field.

ATTENDANCE OPTION
Please indicate which week(s) you would like to attend:*

PERSONAL INFORMATION OF PRINCIPAL INVESTIGATOR
Last Name:* First Name:* Middle Initial:

Mailing Address:*

City:* State:* Zip Code:*

Country:

E-mail Address:* (a confirmation email will be sent to this e-mail address)

EDUCATION

(Note: Only applicants who have completed a doctoral degree are eligible to apply)

Highest Degree Completed:* Primary Specialty:*

School:* Area of Concentration:* Degree:* Year Received:*

School: Area of Concentration: Degree: Year Received:

School: Area of Concentration: Degree: Year Received:

PROFESSIONAL EXPERIENCE (two most recent)
Employer:* Position:* Dates (MM/YY - MM/YY):*

Activities:*

Employer: Position: Dates (MM/YY - MM/YY):

Activities:

Do you have experience with clinical investigation?*

If yes, please list years, institution, and mentor (if applicable):

Note: Maximum of 1000 characters allowed (approx. 100 words)

Current character count:

What do you hope to accomplish by attending this workshop?*

Note: Maximum of 2000 characters allowed (approx. 200 words)

Current character count:

GRANT / PROTOCOL SYNOPSIS

Students will have time to develop their own clinical protocol or grant proposal in a small-group, mentored setting. To apply for the workshop, students should submit their synopsis using the space provided below.

Note: Each section has a maximum number of characters as noted below

Title:*

Note: Maximum of 500 characters allowed (approx. 50 words)

Current character count:

Proposed Co-Investigators:*

Note: Maximum of 500 characters allowed (approx. 50 words)

Current character count:

Number of Centers:*

The following section titles must be used: 1) Study Objective; 2) Background/Rationale; 3) Study Design and Duration 4) Primary Outcome Measure; 5) Secondary and Exploratory Outcome Measures; 6) Study Population; 7) Inclusion Criteria; 8) Exclusion Criteria; 9) Intervention Administration; 10) Safety Considerations and Monitoring; 11) Sample Size and Power; 12) Analysis Plan.

Details:*

Note: Maximum of 6500 characters allowed (approx. 1000 words)

Current character count:

Key References:*

Note: Maximum of 6500 characters allowed (approx. 1000 words)

Current character count:

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Thank you

If you have questions or have difficulty submitting this application, please contact us at: owen.kim@cshs.org