Research Boot Camp Application Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Email Address Question Title * 4. Cell Phone Number Question Title * 5. Job Title Resident Faculty Fellow Nurse Question Title * 6. Department/Program Cardiovascular Disease Emergency Medicine Emergency/Family Medicine Emergency/Internal Medicine Family Medicine General Practice Dentistry General Surgery Hospice & Palliative Care Internal Medicine Interventional Cardiology Medical Physics Medicine-Pediatrics Minimally Invasive GYN Surgery OB/GYN Oral Maxillofacial Surgery Otolaryngology Pharmacy Podiatric Medicine and Surgery Psychiatry Sports Medicine Surgical Breast Oncology Surgical Critical Care Vascular Interventional Radiology Other (please specify) Question Title * 7. May we share your contact information with program participants? Yes No Question Title * 8. Dietary Restrictions Question Title * 9. Previous research education/experience Currently working on research project Worked on research project(s) in past Submitted research abstract(s) to regional or national meeting(s) Presented research work at regional or national meeting Authored/co-authored a pee-reviewed manuscript Other (please specify) Question Title * 10. Briefly describe your research question or idea Question Title * 11. Please indicate research study status on project/idea listed above Preliminary planning stages Draft protocol completed Currently working on research project Question Title * 12. Who is/will be your faculty mentor? Done