Registration Application

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Completion of this form is your application to attend the NRMN-CAN Facilitator Training on March 7-8, 2016. Confirmation emails, which include travel instructions and other workshop details, will be sent by 1/29/16.

Name

Institution

Indiana University

Michigan State University

Northwestern University

Ohio State University

Pennsylvania State University

Purdue University

Rutgers University

University of Chicago

University of Illinois at Chicago

University of Illinois at Urbana Champaign

University of Iowa

University of Maryland

University of Michigan

University of Minnesota

University of Nebraska-Lincoln

University of Wisconsin-Madison

Other:

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What is your title?

Professor

Associate professor

Assistant professor

Scientist or researcher

Associate scientist or researcher

Assistant scientist or researcher

Clinical instructor

Postdoctoral fellow

Clinical fellow

Administrator

Training program director

Other

If you chose other, please specify your title.

Do you have plans to implement mentor training in 2016?

Yes

Unsure

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If applicable, describe your implementation plans (eg curriculum base, career stage of mentors, anticipated dates of training, duration of training etc).

During one section of the training workshop, you will have the opportunity to focus on one of the below curricula. Please select your top 2 curricula choices.

Mentor Training for Clinical and Translational Researchers for the mentors of junior faculty, post-docs, and graduate students across the full spectrum of translational science

Mentor Training for Biomedical Researchers for mentors of graduate students and post-docs engaged in basic biomedical research, primarily conducted in teams in a laboratory setting.

Mentor Training for Clinical and Behavioral Researchers for mentors of both clinical and behavioral researchers working with human subjects, whether it be at the individual, group, or societal level.

Research Mentor Training for all mentors of undergraduate students across the science disciplines including faculty, graduate student and postdoctoral mentors.

Describe your interest in attending this workshop.

Thank you for your interest in attending the NRMN Facilitating Mentor Training Workshop. This survey completes your application. A member of the planning team will contact you by January 29, 2016 to confirm your attendance. Please include any additional comments below.

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