Research Elective and Extended Research Interest Form 2020 Spring

Office of Student Research Bressler, Suite M-019 655 West Baltimore Street Baltimore, MD 21201 410 706 3026 StudentResearch@som.umaryland.edu http://medschool.umaryland.edu/osr

Research Elective and Extended Research Interest Form

2020 Spring - 2021 Spring Semesters
Please use this form to indicate that you are interested in pursuing a research elective or an extended research experience and provide some details, if you have them. If you do not have some of the requested information readily available, you can update your response later using the Edit Link that will be provided in the confirmation email after you submit the form.
Please respond using this form at least 6 weeks prior to the start of the intended research elective or extended reserach.
First Name *
Last Name *
Email *
Current Medical School Year *

MS II MS III MS IV
Interested Research Elective or Experience Type (select all that apply) *

One-Month Research Elective Two-Month Research Elective (Intense Research Experience) Extended Research Elective (more than 2 months)
Applicable semester(s) for the intended research elective or extended research (select all that apply)

2020 Spring 2020 Fall 2021 Spring Not sure which semester yet
Month(s) of intended research elective (select all that apply)

January July February August March September April October May November June December Not sure yet which month
Dates of Extended Research (mm/dd/yyyy - mm/dd/yyyy)
Is this an urgent research elective or extended research?

Yes No
Are there any special circumstances for this research elective or extended research? (If yes, you can choose to either elaborate in the "Additional Comments" below or discuss during advising session with Dr. Carey.)

Yes No
Mentor and Project (select all that apply)

I have a research mentor and a research project ready I have a research mentor and I am in the process of developing my project with my mentor I am in the process of seeking/deciding on a mentor I am just considering a possible research elective or extended research and have not started a search for mentor and project
Additional Information (select all that apply)

I am continuing a research project that I have worked on previously or am currently working on with my research mentor I intend to use this research to produce a scholarly product for fulfilling the FRCT requirement I am an MD/PhD student continuing or extending my thesis research with the same research mentor and research group
Mentor First Name or Known Name
Mentor Last Name
Mentor Department/Division
Mentor Email
example@example.com
Topic or Area of the Intended Research
Additional Explanation or Comments
Thank you for taking the time to complete this form.
Should be Empty: