MD/PhD Research Rotation Approval Form

This form must be completed before starting a research rotation. Work with your research mentor(s) to complete this form, including providing the mentor funding attachment to this form. Please note that this is required for the MD/PhD program regardless of PhD program requirements. If there are separate rotation form(s) for your PhD program, please complete those as well.

Student UID*

Enter student UID number (e.g. U0001111)

Student Name*

Enter student first and last name

Student Email*

Enter student OHSU email address

Rotation Mentor*

Enter rotation mentor first and last name

Rotation Mentor Email*

Enter rotation mentor's OHSU email address

Select or enter value

Rotation Co-Mentor

Enter rotation co-mentor first and last name. If filled, a signature will also be required by this individual.

Rotation Co-Mentor Email

Enter rotation co-mentor OHSU email address

Rotation Start Date*

Rotation End Date*

PhD Program(s)*

Please list all PhD programs the student is seriously considering

Select or enter value

PhD Program Coordinators*

Select PhD Program Coordinator OHSU email address(es) for all PhD programs the student is seriously considering.

Select or enter value

Research Interests or Project(s)*

Briefly describe your research interests or potential project(s) in this lab.

Mentor Funding*

Attach document with mentor's funding from the past 5 years or any secured future funding. Each entry should include: Funding Source, Grant Number, Role on Project, Grant Title, Project Period, and Current Year Direct Costs (if known). List does not need to be exhaustive, but should show that sufficient funds are available if the student were to join this lab permanently. Please note that mentors cover MD/PhD students starting the spring term/April the following year. Please contact the MD/PhD program coordinator if you have questions about this.

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Current Trainees*

List number of current trainees in your lab. Please include type of trainee (e.g.1 graduate student, 2 postdocs, etc). If no trainees list "None."

Recent Lab Publication*

List a recent publication from this mentor’s lab. If no publications list "None."

Trainee Constraints*

Are there any constraints on space or mentorship for this student in your lab? For example, you have two students rotating but only space and funding for one. If no constraints list "None."

SOC Member 1 Email*

Enter one of your SOC member's OHSU email address.

SOC Member 2 Email*

Enter your second SOC member's OHSU email address.

SOC Member 3 Email*

Enter your third SOC member's OHSU email address.

MD/PhD Program Director Email*

Select

MD/PhD Program Director Email approval2

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