2019 HSR Course Nomination Form Question Title * 1. First Name: Question Title * 2. Last Name Question Title * 3. Academic Rank Fellow Instructor Assistant Professor Associate Professor Professor Question Title * 4. Academic Affliliation Emory University Georgia Tech Morehouse School of Medicine University of Georgia Other (please specify) Question Title * 5. School Emory School of Medicine Emory School of Nursing Emory School of Public Health Other (please specify) Question Title * 6. Department Anesthesiology Biochemistry Biomedical Engineering Biomedical Informatics Cell Biology Dermatology Emergency Medicine Family & Preventive Medicine Gynecology and Obstetrics Hematology/Oncology Human Genetics Medicine Microbiology and Immunology Neurological Surgery Neurology Ophthalmology Orthopedics Otolaryngology Pathology and Laboratory Pediatrics Pharmacology Physiology Psychiatry and Behavioral Sciences Radiation Oncology Radiology & Imaging Sciences Rehabilitation Medicine Surgery Urology Other (please specify) Question Title * 7. Division (If applicable) Question Title * 8. Nominated by Self Other (please specify) Question Title * 9. Candidate's Statement (All nominations)Please decribe the level of your current experiance in health services research (max. 100 words) Question Title * 10. What do you hope to gain from this course? (max. 300 words) Question Title * 11. On what HSR-related project do you intend to work after completing the course? (max. 200 words) Question Title * 12. CV File name: Last, First, HSR2017 PDF, DOCX, DOC file types only. Choose File Choose File No file chosen Remove File File name: Last, First, HSR2017 Done