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

 

This K12 Program is not currently accepting new application in 2015.  Stay tuned for any updates if positions become available in the future!


 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.