FRCT Mentor Registration Form

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

Foundations of Research and Critical Thinking (FRCT)UMB School of Medicine Course for Medical Students

Mentor Registration Form

The Foundations of Research and Critical Thinking (FRCT) course has two major components.

1. A series of lectures and associated small group sessions. If you are interested in

teaching in this course, there is a place on the form to indicate this.

2. All students will be required to complete a Scholarly Project under the guidance of

a mentor.

Scholarly Projects can be:

a. Based on basic, translational or clinical research and must be hypothesis-driven.

b. Based on a public health service project.

c. A mentored, hypothesis-based grant application.

If you are willing to act as a mentor for one or more of these Scholarly Projects, please fill out this form.

As part of the The Foundations of Research and Critical Thinking (FRCT) course, all students are required to complete a Scholarly Project under the guidance of a mentor.

Scholarly Projects can be:

Based on basic, translational or clinical research and must be hypothesis-driven.
Based on a public health service project.
A mentored, hypothesis-based grant application.

If you are willing to act as a mentor for one or more of these Scholarly Projects, please fill out this form.

Mentor Last Name:*

Mentor First Name, Middle Initial:*

E-mail:*

Phone Number:*

UM Primary Affiliation:*

Specify Other UM Primary Affiliation:

Department:*

Division (if applicable):

Other Affiliations (UM and Non-UM):

For which of the following types of Scholarly Projects will you be willing to mentor a medical student (check all that apply):*

Summer Research ProjectPublic Health Service ProjectMentored Grant ApplicationOther

How many medical students can you mentor at one time?*

Elaborate, if necessary:

Would you be interested in teaching in the didactic component of the course?

YesNo

Indicate whether or not you can provide stipends for summer research:*

Yes, I can provide stipendsNo, I cannot provide stipends

If you will mentor a student for a research project, please give a brief summary of your research program.*

Please provide your faculty webpage.*

(Optional) Please provide keywords that summarize your research interests/ opportunities.

Additional Comments: