<p> Scholarly Activity Project Proposal Clinical and Translational Research</p><p>Student must have mentor review and sign this form once completed IDENTIFYING INFORMATION STUDENT: STU ID:</p><p>FACULTY BLOCK/DATES: MENTOR:</p><p>MENTOR RESEARCH COOR: DEPT.</p><p>PLEASE LIST COLLABORATORS ROLE (MED STUDENT/RESIDENT) CONTACT INFORMATION</p><p>*THIS AREA IS FOR OTHERS WHO MIGHT HAVE ALSO WORKED ON THIS PROJECT</p><p>PROJECT INFORMATION PROPOSAL IS FOR A NEW PROJECT ☐ THIS STUDENT WILL JOIN AN EXISTING PROJECT☐</p><p>PROJECT TITLE</p><p>IRB OR IACUC Study #: </p><p>If there is not an IRB already, please work through the attached flowchart to see if you need to submit a protocol.</p><p>HOSPITAL &EPIC Which Hospital(s) will the research be at?</p><p>What computer systems will you need access to? This will trigger training and credentialing needs. EPIC, PACS, iSITE, eIRB, Velos</p><p>BACKGROUND Describe your project. How did you identify this project? Why should we care about this project?</p><p>HYPOTHESIS/SPE One sentence underlining the purpose of the research CIFIC AIMS</p><p>STUDY DESIGN Describe the basic elements of your research design. Use words that lay practitioners will understand. What are the student responsibilities in this project? Will they be interacting with patients? Will they be using identifiable data? About 100 words.</p><p>POSSIBLE Summarize how this research fits into other projects in this field. Possibly include CONCLUSIONS/DIS possible beneficiaries of the research and the value this research will add to the EASE RELEVANCE field. PROPOSED DEADLINES WITHIN THE ROTATIONS THAT BOTH STUDENT AND MENTOR NEED TO MEET. TIMELINE OF WEEK 1- ORIENT TO DEPARTMENT GOALS AND WEEK SEND DRAFT TO MENTOR OBJECTIVES 10- WEEK 12- COMPLETE EVALUATION OF PROGRAM AND STUDENT</p><p>During this elective, the mentor and student understand that the student is to spend a full time effort in actively working in the research setting. In order to get credit for this elective, the student will need to submit a final summary of the research done and the mentor will need to submit an evaluation of the student’s progress. Student : Mentor: Signatures</p>