TICR Summer Clinical Research Workshop Application

2008

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Office contact information after July 16, 2008 (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 16, 2008 (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 pertaining to the time the program begins on July 29, 2008

Institutional Title

Institution

UCSF UC Berkeley Stanford
Other:

School

Department

Division

Research Interest

Information regarding your research advisor

Name

Institution

UCSF UC Berkeley Stanford
Other:

School

Department

Division

Information regarding a second research advisor

Name

Institution

UCSF UC Berkeley Stanford
Other:

School

Department

Division

For which courses are you applying?

Course Title

UCSF & UC Berkeley fellows, faculty & staff

No UC affiliation

Choose only one DCR offering:

		Designing Clinical Research (Epi 202)
OR
		Designing Clinical Research for Residents and Students (Epi 150.03)

$1100

$2200

Responsible Conduct of Research

$350

$700

Building a Career in Clinical Research

$350

$700

If you choose all 3 courses the price is reduced

$1650

$3300

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 section leader to be absent for a single week) and to do all the homework ontime.		Agree