Warren Alpert Medical School of Brown University
and
SUBSTANCE ABUSE INTERVENTION OUTCOME RESEARCH TRAINING PROGRAM
Please list faculty mentor(s) you are most interested in working with:
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Name:
Addresses:
Home:
Office:
Email:
Telephone Number(s):
Home:
Office:
Academic Training:
Doctoral Training:
Degree Institution City/State Major Field Minor Field Date
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Dissertation:
Dissertation Title:
At what stage is your dissertation:
__ Preliminary Planning
__ Proposal Meeting Scheduled Date:
__ Dissertation Topic Approved
__ Collecting Data
__ Dissertation Completed
For clinical trainees:
Predoctoral Internship:
Institution City/State Date APA approved (Yes or No)
Academic Training: (Physicans only)
Medical School:
Institution City/State Dates
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Residencies:
Institution City/State Area Dates
RESEARCH SKILLS
(List research areas and/or techniques in which you consider yourself trained or competent)
OTHER RELEVANT AREAS OF COMPETENCE:
(If you have other areas of skills or experience which you think are pertinent to the research you propose, please list or describe them.
For example, this may include clinical training or other experience or skills relevant to treatment or interventions you are proposing to research):
Any other information you consider pertinent:
U.S. Citizenship: Yes _____ No _____ U.S. Noncitizen National _________
Alien Registration #: ________________ Type visa: _________________ Expiration Date: _____________
Start Date:
Indicate time periods during which you would be able to initiate your program if selected.
State earliest month you could begin in 2008 _________________
Brown University, an EEO/AA employer does not discriminate because of race, gender, sexual orientation, age, color, religion, national origin, disability, or veterans status. To assist in Brown’s affirmative action efforts, you are asked to check the appropriate spaces below. This information is voluntary and will remain confidential.
_____ Black or African American _____ Alaskan Native/American Indian
_____ Hispanic or Latino _____ Veteran
_____ Asian _____ Female
_____ White _____ Male
_____ Native Hawaiin or other Pacific Islander
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Part II
Outline for Proposed Research Plan
Note: This is not a binding document. We use it to identify your primary research interest as of this writing, and as an example of how you would go about addressing a
research question of your choice. This document should be not less than two pages and no more than ten.
1. Long term career goals.
2. How a fellowship at the Center will assist you in achieving these career goals.
3. What area(s) you would plan to conduct research in while at the Center.
4. Potential faculty advisors among the training faculty.
5. A particular aim or hypothesis you would want to investigate.
6. A description of the research protocol you might use to conduct the study, including data collection and analysis techniques.