Please print and mail completed form to:
AO North America
Application for Resident Trauma Research Support
Information pertaining to applicant:
LAST NAME: __________________________________
FIRST NAME: __________________________________
DATE OF BIRTH: __________________________________
PERMANENT HOME ADDRESS:
__________________________________
__________________________________
__________________________________
HOME TELEPHONE #: __________________________________
NAME OF UNIVERSITY/HOSPITAL/ TRAINING PROGRAM: __________________________________
NAME OF HEAD OF DEPARTMENT: __________________________________
COMPLETE ADDRESS OF HOSPITAL:
__________________________________
__________________________________
__________________________________
HOSPITAL/OFFICE TELEPHONE #: __________________________________
HOSPITAL/OFFICE FAX #: __________________________________
PRESENT POSITION: __________________________________
DIRECTOR OF ORTHOPAEDIC TRAUMA: __________________________________
RESEARCH PROJECT PRECEPTOR(Sponsoring Faculty): __________________________________
Postgraduate Year : 1 0 - 2 0 - 3 0 - 4 0 - 5 0
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Information pertaining to project (add an additional sheet if necessary):
TITLE OF PROJECT:
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BRIEF HYPOTHESIS:
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PROPOSED METHODS:
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OUTCOMES TO BE EVALUATED:
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BUDGET AND TOTAL AMOUNT REQUESTED:
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(NOTE: If more than $5,000.00 alternate sources of funding must be confirmed)
Please attach protocol of project including a review of literature and any other pertinent supporting data.
AUTHORIZATION (by person authorized to approve RESIDENT RESEARCH):
______________________________
NAME (Please type or print)
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SIGNATURE
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TITLE
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DATE