Research Elective and Extended Research Interest Form 2023-24

Office of Student ResearchBressler, Suite M-019655 West Baltimore StreetBaltimore, MD 21201410 706 3026 StudentResearch@som.umaryland.edu http://medschool.umaryland.edu/osr

Research Elective and Extended Research Interest Form

2023 Fall - 2024 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 *

SOM Email*

Current Medical School Year*

MS IIMS IIIMS IVOther

Interested Research Elective or Experience Type (select all that apply)*

One-Month Research ElectiveTwo-Month Research Elective (Intense Research Experience)Extended Research / Research Selective (more than 2 months)

Applicable semester(s) for the intended research elective or extended research (select all that apply)*

Block(s)/month(s) of intended research elective (select all that apply)*

Dates of Anticipated Research Elective or Extended Research / Research Selective (mm/dd/yyyy - mm/dd/yyyy)*

Is this an urgent research elective or extended research?

YesNo

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.)

YesNo

Mentor and Project (select all that apply)*

I have a research mentor and a research project readyI have a research mentor and I am in the process of developing my project with my mentorI am in the process of seeking/deciding on a mentorI am just considering a possible research elective or extended research and have not started a search for mentor and projectOther

Applicable IRB (human research or human data) and/or IACUC (animal research) approval status

Applicable IRB or IACUC protocol is approved or determined by IRB as exempt or as not need review (can provide a copy of the approval letter or determination letter)Applicable IRB or IACUC protocol is under review pending approval, or modification of protocol is pending approvalIRB or IACUC protocol not yet submitted for IRB or IACUC reviewNo applicable IRB or IACUC protocolI do not know the status of the IRB or IACUC protocolOther

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 mentorI am an MD/PhD student continuing or extending my thesis research with the same research mentor and research groupOther

Primary Reasons for the Research Elective or Extended Research (select all that apply)

Scholarship and tangible enhancements (potential publication, conference presentations, etc.)Broaden residency choices and strengthen residency applicationFulfill FRCT requirementsFulfill elective credit for graduation

Mentor First 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.