Application for Pre-Doctoral Fellowship in The

CTSIPre-DoctoralTraininginTranslationalResearch

APPLICATION

Applicationsmust bereceivedby Wednesday November 15, 2017.

Allmaterialslistedonthe‘Procedures forSubmission’mustbe included,

inonepdffile.Youarerequiredtostaywithinthepagelimitationsstatedforeachindividualquestion.

Please note that you will be submitting through the Indiana CTSI’s new grants management software WebCAMP. Please allow enough time to be familiar with a new system. The WebCAMP user’s guide is also available under the funding announcement here:

Title of Application:
Brief(100-150words)description of theresearchproposal.(Please Note: Upon selection,thisdescriptionwillbeshared publicly.):
Name of Applicant:
Mailing Address:
Telephone Number(s):
Email Address:
Degree Granting Institution:
Degree Granting Department:
Applicants Graduate Program Head:
Email Address:
Date of Birth:
Gender: / Female / Male / Prefer not to respond
Are you Hispanic or Latino? / Yes / No / Prefer not to respond
Ethnicity (please check one or more)*:
African American / Black / Native Hawaiian or other (Pacific Islander)
Asian / Native American; Alaskan Native
White
Other (please specify:
Prefer not to respond

*State and federal laws pertaining to civil rights require the University to report ethnic data. Only U.S. citizens and permanent residents should complete this section. Applicants who select Other should specify ethnic status in the space provided. Applicants who choose to submit this application without ethnic data should select the “Prefer not to respond” option.

Primary Mentor:
Department:
Institution:
Telephone Number: / Email address:
Co-Mentor:
Department:
Institution:
Telephone Number: / Email address:

Information requested in each section below MUST be typed into the amount of space provided for each section. Use of 12 pt Times new Roman or Arial font is required.

1.BriefStatementofResearchPlan: Inthespace belowplease provide abriefdescription ofyourproposedresearch. Describeyourresearchproblem,itssignificanceandinnovation.(Max. length½page)

2.TranslationalNatureofWork: Describehowyourproposedresearchistranslational(e.g.,eitherT1 orT2).(Max.length½page)

3.Clinical/TranslationalMentorshipPlan: In the space belowdescribe howyou haveinteractedorwillinteract withyourco-mentors and theplannedcontributionsof each. Inconsideration of yourcurrentstrengthsandweaknessesforconducting translationalresearch,whatwillbe the specific rolesof yourbasic and clinicalmentorsinyourtraining?(Max.length½page)

4.DescriptionofTrainingPlanandRationale:Describe yourspecifictraininggoals(e.g.,additionalcourses,readings,clinicalrotations/experiences,conferences/meetings)and howthey will be satisfied.(Max.length½page)

5.ResearchProposal: Pleasedescribe yourproposedresearchincluding specificaims,design, briefdescription ofmethods,potential pitfallsand alternativeapproaches,and expectedoutcomes.(Max. length 1page)

6. ResearchBackground/Experience: Inthe space providedbelowsummarize yourresearchexperienceto date.Speakspecifically to anyresearchprogressmadeinyourcurrentprogramof research.(Max.length1page)

7.DescriptionofExperientialLearningOpportunity: The NIHis nowencouragingsometype of experiential learningopportunityforindividualson traininggrantsinavenueoutsideofthe trainee’scurrentresearchteam. Examples caninclude(but arenotlimited to)briefexperienceswithanindustrypartner,government agency, community organization,orhealthcare setting. Inthe spaceprovided, givean example of experiential learning (shortorlong)thatwouldexpand yourresearchandbroadenyourunderstanding of the field anditsapplicationtohuman healthanddisease. Theseexamples are notbindingand willnotinfluence theevaluation ofyourproposalbutareintendedto stimulatediscussionconcerning this concept.

(Max. length½page)

8.Literaturereferences:(nopagelimitation onreferences)