Faculty Name:

 Contact Phone:

 Email:

 Department:

For which pathway (s) does this project apply (check all that apply):

Clinician Educator (health profession education)

Global Health (international implications)

Master Clinician (clinically relevant)

Physician Scientist (hypothesis driven translational, clinical, basic science or outcomes research)

Quality Improvement & Patient Safety

Urban and Community Health (community engaged)

Brief Description of Project Idea:

Anticipated outcomes of the project (e.g. product, report?):

Time commitment (e.g. duration of project -- note: students generally have one afternoon each week available – usually Thursday afternoons)

How many students can work with you on this project?

List specific skills or attributes required or preferred (e.g. language, transportation), if applicable: