* 1. Faculty Sponsor * Name: * Degrees: * Title: * Organization: * Address: Apt/Suite: * City: * State: * Zipcode: * Office Phone: * Email Address: 2. Daily Supervisor Name: Degrees: Title: Organization: Address: Apt/Suite: City: State: Zipcode: Office Phone: Email Address: * 3. Project Title (250 words limit) The number of words left is * 4. Up to three faculty publications (within the last three years). Projects without recent publications are unlikely to be filled. * 5. Sponsor's Research Focus: Anatomy Gastroenterology Ophthalmology Anesthesiology Genomics Pediatrics Biochemistry Geriatrics Pharmacology Cancer Infectious Disease Psychiatry Cardiology Kidney Pulmonology Dermatology Neurology Radiology Emergency Medicine Obstetrics/Gynecology Surgery Endocrinology * 6. Sponsor's translational level * (Please select ONE) Please Select T0/T1: Basic Science Discovery and Initial Translation to Humans T2: Translation to Patients T3: Translation to Practice T4: Translation to Population Health * 7. Hypotheses (200 word limit) The number of words left is * 8. Project goals and measureable objectives (e.g. number of patient records, assays completed) (200 word limit). The number of words left is * 9. Overall design of the research project (500 word limit). Please describe time frame and breakdown of activities. Selection criteria include: The project design makes it likely that the objectives will be achieved The project is likely to result in a report of interest to other scholars The project fulfills discovery/original research The number of words left is * 10. Describe the student's role in the project (200 word limit) The number of words left is * 11. Describe the mentor's role in the project. (200 word limit) The number of words left is * 12. Describe the current and previous medical student training by your mentor team. Indicate any Gill Fellows. (200 word limit) The number of words left is * 13. Do you have or will you obtain IRB approval for this project?Please note: Students cannot begin a human subjects project without IRB approval. * (Please select ONE) Yes No (Pending) No (Not required) Please provide IRB number and date * IRB Number: * IRB Date: Please specify why it is not required.