CTSI K to Independence Program Application Form

The K TO INDEPENDENCE program was developed to foster the successful transition from mentored research training (e.g., K awards) to sustained, independent research programs (e.g., R awards). This program will build upon the five levels of mentorship underlying the overall success of the CTSI-Senior, Scientific, Self, Peer-to-Peer, and Staff. The program will consist of a didactic component as well as peer engagement, a writing accountability group, and mentorship from successful, senior faculty members.

First Name:

* must provide value

Last Name:

* must provide value

Middle Initial:

* must provide value

eRA Commons Username (if applicable):

Kerberos Username (if applicable):

Other current school or institutional ID (e.g. Washington Square):

Gender

* must provide value

Date of Birth:

* must provide value

M-D-Y

Citizenship:

* must provide value

Current Institution:

* must provide value

Current Position:

* must provide value

Department:

* must provide value

Division:

* must provide value

Home Address:

* must provide value

Home Phone:

* must provide value

Preferred E-mail:

* must provide value

Work Address:

* must provide value

Work phone:

* must provide value

Work E-mail:

* must provide value

Do you consider yourself to be:

* must provide value

What is your racial background (check all that apply):

* must provide value

American Indian/Alaska Native

Asian

Black or African American

Hawaiian/Pacific Islander

White

Other

Do not wish to provide

Do you have a disability?

* must provide value

If yes, which describes your disability?

* must provide value

Are you from a disadvantaged background?

* must provide value

Type of K Award

* must provide value

Title of K Award

* must provide value

Synopsis of K Award (50 words or less)

* must provide value

Upload file

Nomination from Department Chair (including assurance of protected time for complete participation in program)

* must provide value

Upload file

Departmental support for administrative fee:

* must provide value

Upload file

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.