2009

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IF YOU ARE IN THE MASTER'S IN CLINICAL RESEARCH OR ATCR CERTIFICATE PROGRAM, DO NOT FILL OUT THIS APPLICATION. 

Identity
First Name  Middle Initial
 
Last Name  Degree
 
Date of Birth (MM/DD/YYYY)  
 
Country of Citizenship  Gender
  Male Female
Race/Ethnicity  Email Address
 

Office contact information after July 10, 2009
(Use home info if office is not applicable.
If info is not known, skip to the next section.)
Office Address (Line 1)        Daytime Phone #1
      
Office Address (Line 2)        Phone Extension
      
City        Fax Number
      
State     Email Address
   
Zip Code
UCSF Box #

Office contact information before July 10, 2009
(If different from above.)
Office Address (Line 1)        Daytime Phone #1
      
Office Address (Line 2)        Daytime Phone #2
   
City     Fax Number
   
State        
       
Country
Zip Code
UCSF Box #

Information about you as of August 1, 2009
Institutional Title
Other:
Institution
UCSF UC Berkeley Other:
School
Department
Other:
Division (if applicable)
Research Interest
      

Information regarding your research advisor
Name
Institution
UCSF UC Berkeley Other:
School
Department
Other:
Division (if applicable)

Information regarding a second research advisor
Name
Institution
UCSF UC Berkeley Other:
School
Department (if applicable)
Other:
Division (if applicable)

For which courses are you applying?
  Course Title
UC affiliation†
No UC affiliation
Choose only one Designing Clinical Research (DCR) offering:
Designing Clinical Research for Residents and Students (Epi 150.03) held Aug 3-28, 2009, Mon & Wed mornings.
For residents and students.
OR
Designing Clinical Research (Epi 202) held Aug 4-Sept 15, 2009, Tues mornings.
For fellows, faculty, academics, and staff.
$1155
$2310

Responsible Conduct of Research (Epi 201)
$370
$740

Building a Career in Clinical Research (Epi 227)
$370
$740
If you choose all 3 courses the price is reduced
$1725
$3450

† Concurrent enrollment in a UCSF/UCB sponsored residency or post-doctoral fellowship program; student at UCSF/UCB; or individuals who hold full-time salaried UCSF/UCB faculty, academic, or staff positions.

Payment information
Will any portion of your fees be paid by a UCSF account or department?
Yes   No

Is there any other information relevant to your application which we should know?

Commitment
(Experience has shown that requiring this in advance makes things work better all around):
I promise to attend all the sessions (unless I pre-arrange with my DCR section leader to be absent for a single week) and to do all the homework ontime. Agree


 

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