K12 Application Form

University of Pittsburgh Emergency Medicine K12 Research Training Program Application for 2014

 Download This Form

Instructions:

• Applications and letters of recommendation must be received by November 1, 2013. Depending on applications and available positions, we may announce later dates for additional applications. 
• Your application will be complete when we have the following: 

1. Complete application form
2. Curriculum vitae 
3. Personal Statement  (~500-1000 words)
4. Three Letters of Recommendation  

 

Mailing Address:                                                                       

 

Clifton W. Callaway, MD, PhD

University of Pittsburgh

Department of Emergency Medicine

Iroquois 400A

3600 Forbes Avenue

Pittsburgh, PA 15260

 

 

 PERSONAL INFORMATION

Last Name:	First Name:		Middle:
Address:
City:	State:		Zip:
Country:
EMAIL:		Phone:

 

 

EDUCATION

Undergraduate

School
Address
Degree
Dates of Attendance
Field of Study

 Graduate

School
Address
Degree
Dates of Attendance
Field of Study

 Medical School

School
Address
Degree
Dates of Attendance
Field of Study

Other

School
Address
Degree
Dates of Attendance
Field of Study

  

POST GRADUATE EDUCATION (Please include complete address)

 

RESIDENCY TRAINING:

Specialty
Hospital
Program Director
Address
Phone Number
Dates of Training

 

FELLOWSHIP TRAINING (If Applicable):

 

Specialty
Hospital
Program Director
Address
Phone Number
Dates of Training

OTHER TRAINING/EXPERIENCE:

 

Specialty or Field
Hospital /Institution
Program Director
Address
Phone Number
Dates of Training

 

DEMOGRAPHIC INFORMATION:  This information is for NIH Reporting
purposes. 

 

Date of Birth
Gender:
US Permanent Resident or Citizen
Race / Ethnicity (Check all that apply:	American Indian or Alaska Native		Asian		Native Hawaiian or Pacific Islander		Hispanic
	Black or African American		White				Non-Hispanic

 

REFERENCES: Please list the full name, telephone number and email address of three individuals who will provide letters of recommendation. One letter should be from your current program director. Letters should be sent to Dr. Yealy or Dr. Callaway at the address below. 

 

 

Name:
Institution:
Email	Telephone:

 

 

Name:
Institution:
Email	Telephone:

 

 

Name:
Institution:
Email	Telephone:

 

 

Clifton W. Callaway, MD, PhD

University of Pittsburgh

Department of Emergency Medicine

Iroquois 400A

3600 Forbes Avenue

Pittsburgh, PA 15260

Phone 412-647-3078

FAX 412-647-6999

callawaycw@upmc.edu

 

PLEASE PASTE A COPY OF YOUR PERSONAL STATEMENT HERE OR SEND TO US VIA EMAIL.

Describe your interest in an investigative career.  Indicate how the K12 program will facilitate your progress towards independent investigators.  We are particularly interested in the topics or areas where you would like to do research.  It is not necessary to describe specific aims or projects, but you can speculate about the scope or focus of career training grants or project grants that you might pursue.