Summer Clinical Research Workshop Application


Workshop Start Date: July 28, 2015

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If you applied to the Master's in Clinical Research Degree or ATCR Certificate Programs, do not complete this application.

Identity
First Name  Middle Initial
 
Last Name (Surname)  Degree
 
Date of Birth (MM/DD/YYYY)  
 
Country of Citizenship  Sex
  Male Female
Race/Ethnicity  Email Address (must be active during the workshop)
 
Cellular(Mobile) Phone # (add country code if not US, digits only)  UCSF Box # (if known)
 
Information about you as of the Workshop Start Date
Institutional Title
Institution
School
Department
Division
Research Interest
Information regarding your research advisor
Name
Institution
School
Department
Division
Information regarding a second research advisor
Name
Institution
School
Department
Division
For which courses are you applying?
  Course Title
UC affiliation†
No UC affiliation
Choose only one Designing Clinical Research (DCR) offering
Designing Clinical Research (One Month) (EPI 150.03)‡
Aug 3-24, 2015, Mon & Wed mornings (Parnassus campus)
Course type:Classroom   Online
OR
Designing Clinical Research (Two Month) (EPI 202)
July 28-Sept 8, 2015, Tues mornings (Mission Bay campus)

Course type:Classroom   Online
$1885
$2828

Introduction to Statistical Computing (BIOSTAT 212)
July 28-Sept 8, 2015 Tues afternoons (Mission Bay campus)
Course type:Classroom   Online
$1447
$2170

Database Management (EPI 218)
July 30-Sept 10, 2015 Thurs mornings (Mission Bay campus)
Course type:Classroom   Online
$1447
$2170
Concurrent enrollment in a UCSF/UCB-sponsored residency or post-doctoral fellowship program that is recognized by the UCSF Office of Graduate Medical Education; or a registered student in one of the professional schools or graduate programs at UCSF/UCB (in a program other than the TICR Program); or individuals who hold full-time salaried UCSF/UCB faculty, academic or staff positions. Individuals will be asked to provide proof of UCSF/UCB status.
EPI 150.03 is currently being offered at the low rate of $150 for UCSF residents. This rate is made possible by the support of the CTSI Resident Research Training Program. UCSF residents also have the option to take DCR for Residents later in the year for the same price, although that course will involve online rather than in-person lectures.
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?
(Limit of 1400 characters)
(Next you will review your data for accuracy before submission)

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