Summer 2017: UTHealth-CPRIT Undergraduate Cancer Prevention Research Experience

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Name:
last or family name first middle name you go by
Current
Address:
Permanent
Address:
Phone: / Cell: / Home:
E-mail 1: / E-mail 2:

Communication will be primarily by e-mail.

All positions will be full time (40 hours per week), beginning on Monday, June 1, 2015 and ending on

Friday, July 24, 2015 ($4000 stipend) / or / Friday, August 07, 2015 ($5000 stipend)

Please rank your site preference(s), 1 being the highest:

Houston / Austin / Brownsville / Dallas / El Paso / San Antonio

List all colleges and universities attended, beginning with your current institution.

Full name of
institution, location / Dates
attended (month/year) / Major field of study / Degree Expected or Earned / Expected Graduation (month/year) / GPA
*Must have a minimum GPA of 3.5 in order to be considered for the program. Overall GPA:

What will be your academic level this fall? (Sophomore, junior, senior) ______

Are you planning to attend graduate school? _____yes _____no _____undecided/maybe

What degree in what field of study would you seek?
Other future plans?

If any information relevant to this application is under a different name, please list those name(s):

This application is available @ http://go.uth.edu/CPRIT-summer

E-mail us with any questions at

Test scores: Please enter scores for any of the following tests you have taken. If you are accepted to the program, you will be required to submit photocopies of your official score reports.

ACT
Test / Not Taken: / Date Taken: / English: / Math: / Reading:
Science: / Composite: / Writing:
SAT Reasoning Tests / Not Taken: / Date Taken: / Critical Reading: / Math: / Writing:
SAT Subject Tests / Not Taken: / Date Taken: / Subject: / Score:
Date Taken: / Subject: / Score:

Interests for the Summer Research Experience

Please check your top 3 to 5 choices for a research experience this summer.

Promoting healthy behaviors (such as diet, physical activity, cessation of tobacco use). / Computer simulation and modeling to find potential cancer clusters
Environmental or occupational factors contributing to cancer risk / Looking at how cancer gets started and spreads (mechanisms of carcinogenesis and metastasis)
Health communication and literacy / Impact of government policy (e.g., taxes) on behavior (e.g., quitting smoking)
Distribution of risk factors and cancers by demographic groups (research in epidemiology) / Policy analyses
Mathematical models of risk
Differences in cancer rates among various populations (disparities research) / Economic evaluations
Electronic medical records and claims data: using them to improve cancer prevention and surveillance / Geographical information systems (using computer mapping to look at neighborhood data) to enhance community health planning
Using clinical data for research and quality improvement, data mining: finding spatial or temporal patterns in large cancer related data sets / Social network analysis
Statistical analysis of large datasets / Technology-mediated health promotion

If there are any other areas you might find of interest, please let us know:

Goal Statement

Using the space provided below, please tell us about your career goals and interests.

An academic letter of recommendation is required. Please request the faculty member below to prepare your letter of recommendation and send it to ; the file name should be LAST-FIRST-LOR (your last name, your first name, and LOR for “letter of recommendation”).

Name, degree:
Title, institution:
Phone: / e-mail:
The following information is used for reporting purposes to our funder. No information provided will be used in a discriminatory manner:
Are you a US Veteran? / Yes / No
Are you Hispanic/ Latino: / Yes / No
Race:
White / Black / Asian / Others
Country of citizenship:
If you are not a U.S. citizen, are you classified by ICE as a “permanent resident” or “alien resident” of the United States? / Yes: / No:
If you are not a U.S. citizen or resident, do you hold a student visa? / Yes: / No:
Mother’s highest degree earned: / Father’s highest degree earned:
Your first language:
Primary language spoken at home:
Have you ever been convicted of a felony? / Yes: / No:
If yes, please give details including dates:

[ ] I understand that if I am selected I will be required to provide official copies of transcripts and test scores, and the Observer/Trainee/Visiting Scientist (OTVS) application form* with all accompanying documents, including a health history form, proof of T.B. testing within 6 months of start date (if necessary for my project), a letter from my home institution, a background check consent form, and a copy of my driver’s license or other state-issued photo ID, for approvals no later than Friday, March 31st, 2017. Failure to do so in a timely manner may result in my stipend being delayed or prevent me from participating in the program altogether.

*The OTVS application form is available on the CPRIT Summer website (http://go.uth.edu/CPRIT-summer). We recommend you familiarize yourself with the application and all necessary materials prior to, or immediately after, submitting your application.

[ ] I understand I will be required to sign a learning contract with my summer preceptor.

[ ] I certify that I am able to start on Monday, June 5th.

International Students: If you are not a U.S. citizen or permanent resident, you must contact the Office of International Student Affairs, or equivalent office, at your school to determine what extra steps may be required of you to accept this position depending on your visa credentials. There will only be a short period of time between final selections and the due date for hiring paperwork. Again, failure to turn in paperwork in a timely manner may result in your stipend being delayed or prevent you from participation altogether.

By submitting this application, I certify that the information in the application and related documents is complete and correct to the best of my knowledge and belief. I acknowledge that the submission of any false information is grounds for appointment revocation, or appropriate disciplinary action after appointment.

Signature of student / date
E-mail to a single PDF document containing the following:
This application form with attached “Student Stipend Payroll Information Form”
A copy of your CV or resume
Unofficial copies of all college transcripts, scanned or downloaded. (Official copies will be required if you are accepted to the program)
as a single PDF document titled LAST-FIRST-APP (your last name, first name, and “App”).
Only PDF’s are acceptable. If you have problems creating the PDF, talk to your career center.