Intern/Volunteer Application for Research Preceptorship

Instructions

Please email your resume to rockiy.ayettey@yalegriffinprc.org and complete the form below.

Name

Address

Phone Number

Please enter your phone number with area code.

Email Address

Academic Information

School

Degree Program and Major

Expected Date of Graduation

Prior Academic Experience/Degrees

School/Dates Attended/Degree

School/Dates Attended/Degree

How you heard about the PRC

Availability by Semester (hours per week)

Fall

Hours per week.

Spring

Hours per week.

Summer

Hours per week.

I am seeking a paid position

YesNoEither

PRC-Related Interests

Describe your reasons for applying to the PRC

Please describe related research experience.

Please state your objectives for this experience.

Academic Requirements

Is this to fulfill any academic requirements? Please explain.

Please rate your research skills.

Very StrongStrongModerateWeakVery Weak

Skills you would like to acquire or improve

Experiences Sought

What would make this a satisfying experience for you?

Community-based Experience

Please describe any experience you have working in a community-based setting.

List specific PRC projects you are interested in

Refer to http://www.griffinhealth.org/prc/ResearchFindings/CurrentCompletedProjects.aspx for description of active research studies.

Please provide three references.

Reference 1

Name (1)

Phone Number (1)

Please provide phone number with area code.

Email Address (1)

Reference 2

Name (2)

Phone Number (2)

Please provide phone number with area code.

Email Address (2)

Reference 3

Name (3)

Phone Number (3)

Please enter ten-digit phone number.

Reference 3 Email Address

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