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Faculty
Sign-up Form
Please
complete and submit to Robin Catino: fax# (310) 794-2199,
e-mail: rcatino@mednet.ucla.edu
Last
Name:_______________________________
First
Name:_______________________________
Middle
Initial:________
Degree:_________________________
Department:___________________________
_____________________________________
Address:_____________________________________
Campus
Room #: Campus Mailcode:_________________________
City:____________________
State:________ Zip:_____________
Phone
#:______________________Fax #:____________________
E-mail
Address:___________________________________________
If
you have a profile already on the web, please give us
the web address so that we may provide a link to it:
If
you do not have a profile on the web, please provide
us with a brief biographic sketch and we will create
one for you. This will assist the students in their
research for a mentor that will meet their interest:
Under
the appropriate category, please give a topic and a
brief description of your research opportunities for
medical students during the summer:
Basic
Science Research:_______________________________
___________________________________________________
___________________________________________________
Clinical
Research:_____________________________________
___________________________________________________
___________________________________________________
Health
Services Research:______________________________
___________________________________________________
___________________________________________________
Clinical
Epidemiology Research:__________________________
____________________________________________________
____________________________________________________
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