HOWARD UNIVERSITY COLLEGE OF MEDICINE MSSRP APPLICATION FOR MEDICAL STUDENT SUMMER RESEARCH PROGRAM Application Deadline Date: 01/09/17 Program Dates: 05/22/17 to 07/10/17 **** Electronic Applications will not be accepted before 12/12/16 ********* Please return your MSSRP Electronic Application and CITI certificate to com_research@howard.edu 1) Demographic Information Student s Name: Undergrad Year: Undergrad Coll Major: Undergrad1Coll Minor: Graduate Degree and Major: Contact Information: Student Address: Student Telephone: Student e-mail: Family Contact: Relationship: Family Contact Telephone: Selection and Participation in the HUCM Medical Student Summer Research Program is contingent upon the availability of funds 1
All Applicants 1) Must Be In Good Academic Standing In Order To Participate In The Summer Research Program Participating students must pass all freshman medical school courses. Students in remediation may not participate in the program. 2) Must Complete On-Line Training Certification before application submission Please go to site http://www.citiprogram.org/. Note, you should not have to pay for The CITI course First Time Registration on CITI You will have to select "create an account" on the first page. This will take you to second page named CITI Learner Registration. Please type in "Howard University" under "Search for organization: Enter full or partial name "Howard University Medical Center" will appear in blue. Select "Howard University Medical Center". Next Select the "Continue to Step 2" button. You will be taken to a page named CITI - Learner Registration - Howard University Medical Center. Please fill in your information, email, and continue through the registration process. Select a user name and a password and complete your registration. Now you may log into http://www.citiprogram.org/ with the username and password that you have selected earlier. Please Select the Human Subject Biomedical Training Module. Additional Training Modules May be Required. ***All participants must submit evidence of on-line training completion. Please print and save a copy of your CITI training certificate. You may attach an electronic copy of your CITI certificate along with this electronic MSSRP application. 3) **** A final list of all potential MSSRP Projects will be provided at a later date in early December. ***** Note, your MSSRP application may be signed, saved as a PDF, and printed for your review before you email it and your CITI certificate to com_research@howard.edu. ***** Please save your MSSRP application pdf as "your name 2017 MSSRP Application.pdf" 2
II) Applicant Research Interests Student s Name: Select up to 3 of the following that best describe your research interests (indicate 1, 2, 3): Biochemistry Pathogenic Micro Nanotechnology Bioinformatics Cell Biology Developmental Biology Genetics Microbiology Internal Medicine Virology Immunology Molecular Biology Infectious Diseases Neuroscience Cancer Research Pharmacology Structural Biology Allergy/Asthma Cardiology Endocrinology ENT Epidemiology Family Medicine Gastroenterology Hematology OB/GYN Oncology Ophthalmology Orthopedics Pathology Pediatrics Psychiatry Radiology Radiation Oncology Surgery Genomics Microbiology/Immunology Pharmacology Anatomy Physiology Psychology Urology Public Health Disparities Obesity Diabetes Please list Specific Other Please list yourmssrp research project in order of preference ******Please Note That A List of Potential MSSRP Projects will be provided at a later date.*****) Project 1 PI: Project Title: Project 2 PI: Project Title: Project 3 PI: Project Title: 3
Student s Name: III) Prior Research Work Experience: (e.g., full time, part-time, voluntary, laboratory, postgraduate training, etc.) 1) Position and Research Institution: Please state the aim of the research and list your participation / accomplishments in the project. Start Date: End Date: Supervisor : Contact information: 2) Position and Research Institution: Please state the aim of the research and list your participation / accomplishments in the project Start Date: Supervisor : Contact information: End Date: 4
IV Short Essay Provide the following information in a short essay form. Please answer in 100/ 150 words or less. 1) Why do you want to do research? 2) What are your career goals? 3) What are your research career goals? 4) How do you anticipate participating in this program will help your future career goals? 5) How did you become interested in the research areas identified in section II? 5
V Essay If you had the opportunity to do research, describe your ideal research project, the problem to be addressed, and the role you would like to play. If accepted, it is required that you: (1) prepare a poster on your research findings that is formatted in accordance with a format disseminated by the Office of the Dean for Research; (2) participate in and present your data at a symposium at the beginning of the new academic school year in July/August, 2017 and also at the Spring 2018 Howard University Annual Research Week; and (3) maintain good academic standing. Student s Name (Print): Student s Signature: 6