Summer Clinical Research Workshop Application


Workshop Start Date: July 29, 2014

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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 4-25, 2014, Mon & Wed mornings (Parnassus campus)
Course type:Classroom   Online
OR
Designing Clinical Research (Two Month) (EPI 202)
July 29-Sept 9, 2014, Tues mornings (Parnassus campus)

Course type:Classroom   Online
$1754
$3509

Introduction to Statistical Computing (BIOSTAT 212)
July 29-Sept 9, 2014 Tues afternoons (China Basin)
Course type:Classroom   Online
$1346
$2693

Database Management (EPI 218)
July 31-Sept 11, 2014 Thurs mornings (China Basin)
Course type:Classroom   Online
$1346
$2693

Building a Career in Clinical Research (EPI 227)
July 31-Sept 11, 2014 Thurs mornings (China Basin)
$550
$1100
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.
EPI 150.03 is offered free of charge for UCSF residents in 2014, but tuition may be charged in 2015 and beyond. Support for residents is provided by the CTSI Resident Research Training Program. UCSF residents also have the option to take DCR for Residents Online in October free of charge (supported by the CTSI RRTP).
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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