Application for Volunteer Work in Radiology Research

Please complete this form if you are:

A student, trainee, or medical professional interested in working with a clinical Radiology faculty member on a research project
A clinical Radiology faculty member who would like to onboard a student or trainee to your project.

I am the research volunteer completing this form

I am a Radiology faculty member completing this form

Today's date

VOLUNTEER'S INFORMATION

Last Name*

First Name*

Type of Volunteer*

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Type of Volunteer: Other description

Are you here on a Visa?*

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Type of Visa*

Email Address*

Phone Number*

Street Address

City, State, Zip Code

Country

Desired start date*

Desired end date*

Desired number of hours

Are you registered for Radiology Research 7110

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Session Number

Area of Interest (check all that apply)

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Other areas of interest

Special Area of Interest

Referred by

Have you completed CITI training?*

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FACULTY INFORMATION

Faculty Member's Name*

Faculty Team*

Project Title*

OnCore #

Scope of Volunteer's Work*

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No Patient Contact Work Options (check all that apply)

Select

Patient Contact Work (check all that apply)

Select

Patient Intervention Work (check all that apply)

Select

Access Needed (select all that apply)*

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Other Access Needed

Location(s) student working at (select all that apply)*

Select

Other Clinical Locations

Notes

File Upload

Please upload your CV and CITI certificate (if completed)

Drag and drop files here or

NOTE:

Volunteers, please select the box below to have your responses emailed to you. The email message will also contain more information on how to proceed to get connected with a faculty research study.

Send me a copy of my responses

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