Students & Future Residents

 

 

April Vale

Administrative Associate

740.593.2380

valea@ohio.edu

 

CORE Research Preliminary Submission Short Form
CORE Research Preliminary Submission Short Form

Please complete this form in its entirety.

First Name:

Last Name:

Your Status:

Date (yyyy-mm-dd):

Indicate your Specialty College ( Applicable only for Intern/Resident and Faculty):

Institutional Affiliation (hospital):

Current Email Address:

Current Mailing Address and Phone Number :

Street Address:

City:

State:

Zipcode:

Daytime Phone #:

(Please enter in this format: 740-593-2380)

Study Design:

Title of Your Research (Please use all Caps):

Name and Contact Information of your Attending Physician / Mentor :
(Applicable only for Students and Interns/Residents)

First Name:

Last Name:

Degree/Title:

Mailing Address and Phone Number:

Street Address:

City:

State:

Zipcode:

Daytime Phone #:

(Please enter in this format: 740-593-2380)

Email:

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