1. Laboratory Research Program for FMUSP Students at HSPH

APPLICATION DEADLINE: May 20, 2015 (Wednesday)
DURATION OF THE PROGRAM: Early January 2016 to January 2017
ELIGIBILITY: Current FMUSP students who will have successfully completed at least two and up to five years by December 2015

(for additional information on the Program, see http://uspharvard.blogspot.com)

1. First Name

2. Middle Name

3. Last Name

4. Are you a current FFLCH student?

5. Contact Information

6. What is your current year at FMUSP?

7. Have you participated in any extracurricular activities, student groups, Centers, Associations, Leagues, etc. (for example, Associação Atlética Acadêmica Oswaldo Cruz, Bandeira Científica, Centro Acadêmico Oswaldo Cruz, Departamento Científico, Extensão Médica Acadêmica, MedEnsina, Medicina Júnior, Show Medicina, or other activities outside of medical school)? If yes, please describe the nature of your participation below.

8. Have you participated in “Iniciação Cientifica”? (Please check all applicable boxes)

9. If you answered "yes" above, please mention the laboratory and your mentor, while briefly explaining the research area, techniques you learned and your degree of participation. Please include information on participation in medical congresses/conferences and any prizes or recognition received.

10. If you received sponsorship from any of the following institutions, please specify the duration- in months- and the respective Principal Investigator(s):

11. What are your research interests and what is the importance of research in your medical career?

12. What positions of leadership and responsibility have you held in high school or medical school? List no more than 5 and briefly explain.

13. Would you feel comfortable sacrificing animals in the laboratory?

14. LANGUAGE SKILLS (in addition to Portuguese). If you are identified as a potential participant in the program, you will be interviewed in English to assess your fluency and ability to actively engage in collaborative research.

  Intermediate Advanced Fluent Native
Other 1
Other 2
Other 3

16. RESUME. Please submit your Curriculum Vitae to the following e-mail address: afonsosabento@uspharvard.com
[Subject line for your message: "FMUSP/HSPH Research Collaboration - Resume"]

If you have a Lattes Curriculum, please paste the hypertext link below:

17. TRANSCRIPT. Please submit your "Resumo Escolar" from JupiterWeb to the following e-mail address: afonsosabento@uspharvard.com.
[Subject line for your message: "FMUSP/HSPH Laboratory Research Collaboration - Transcript"]

If possible, also paste the hypertext link below:

18. REFERENCES. Please provide the name and e-mail address of two references whom the selection committee can contact, if/as appropriate. This should include at least one FMUSP faculty member and could also include work supervisors, or other professional or volunteer organization contacts.

19. Have you received any financial aid during medical school?