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/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

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a59tImP3TCAvZLnuPnwEDxASwJZwvK4Nv4YIayoUo8umh8eiPyqEWHL9xFzv8K4CGB8

CTRI - CREST Application

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ENROLLMENT STARTS: Summer - JUNE/JULY Winter - JANUARY

Please complete the Application fo CREST program below.

Thank you!

*UC San Diego has implemented a new name policy for students as of Fall Quarter 2023. You may now enter a lived name, including first, middle, and last if you would like to use the lived name instead of your legal name. Click here to learn more about Lived Name. You may also use your legal name. Please, note that the name you enter here will be used and displayed on ALL official University records (including CREST and MAS transcripts, certificate, diploma, etc.) This change is in accordance with the University of California's Gender Recognition and Lived Name policy. https://policy.ucop.edu/doc/2700693/GRLN

First Name*

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Middle Name*

Last Name*

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Date of Birth

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M-D-Y

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Address

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City

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State

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Zip code

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Phone

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Cell Phone

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Gender Identity:
Any information you provide in this section will be used for statistical analysis only. It will not be used in your admission evaluation and will have no bearing on your eligibility for admission.

How do you describe yourself?

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What sex were you assigned at birth such as on an original birth certificate?

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Sexual Orientation:
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Do you consider yourself to be ...

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Heterosexual or straight

Not listed above

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Gender Expression:
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A Person's appearance, style, dress, or mannerisms, (such as the way they walk or talk) may affect the way people think of them. On average, how do you think other people at school would describe your appearance, style, dress, or mannerisms?
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Mostly masculine

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Title

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If your Educational Background is not MD, a copy of all undergraduate and graduate courses work/transcripts must accompany your submission. You could upload it here, or email as attachment schernet@ucsd.edu or fax to 858-534-9168

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Residency Status

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Ethnicity

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Racial Background

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Do you have a disability?
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Are you from a disadvantaged background?
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Yes

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Doctoral Candidate

Post Doctorial Fellow

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Faculty

Pharmacist

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If doctoral candidate or fellow, anticipated date of completion of fellowship/doctoral degree

M-D-Y

Are you now or have you ever been an investigator on a funded grant?

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Yes

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if Yes

K-23 grant

K-08 grant

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Potential grant funding date

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Current Job Title

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Field/Department

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Company (UCSD, VA, Children's Hospital, SD. Hospice)

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Total # of years of relevant work experience

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Relevant work experience (describe in detail)

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Which CREST Track are you applying for?

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Track I (individual course(s): enrollment is on a space available basis

Track II (for Advanced Certificate/ continue for a Master's Degree in Clinical Research)

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If Track I, which course(s) are you interested in taking? (Course description and schedules are available on the web at https://actri.ucsd.edu/education/crest-program

Epidemiology I

Epidemiology II

Patient-Oriented Research I

Patient-Oriented Research II

Biostatistics I

Biostatistics II

Health Services Research

Data Management & Bioinformatics

Scientific Communication Skills

If Track I, which course(s) are you interested in taking? (Course description and schedules are available on the web at https://actri.ucsd.edu/education/crest-program

Epidemiology I

Epidemiology II

Patient-Oriented Research I

Patient-Oriented Research II

Biostatistics I

Biostatistics II

Health Services Research

Data Management & Bioinformatics

Additional Modules

Effective Communication

Research Budgeting and project management

Additional Modules

Scientific Communication Skills

Personal Development Skills

Research Budgeting and project management

Do you have a current Research Project?

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Yes

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Name of the Mentor/Supervisor

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Title of Principle Research Project

Brief Description of Principal Research Project

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Briefly, what are your career goals

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What do you hope to gain from participating in the CREST program?

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How did you hear about the CREST program?

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Please attach Resume or Curriculum vitae

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Agreement of Primary Supervisor/ Program Director/ Research Advisor/ Division Chief/ Clinical Supervisor (blank-please print to get signature)

Attachment:

Agreement of Primary Supervisor20.pdf

Please attach Agreement letter of primary supervisor (signed)

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Please attach statement of purpose

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Please Upload your Photo (picture must be small or 2x2)

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Please submit letters of recommendations (x3) by email: schernet@ucsd.edu

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By filling yes, I certify that the information submitted in this application is complete and correct to the best of my knowledge. I understand that to make a false or fraudulent statement, whether by inclusion or omission, within this application may result in denial of admission or dismissal from program if accepted. I admitted I hereby agree to abide by the policies and the rules and regulations of the CREST program

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Yes

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