SUMMARY APPLICATION FORM

In order to expedite the processing of your application please fill out the following form to summarize your training and experience. Only complete the sections which are applicable to your experience. You may submit your full application materials via e-mail attachment or surface mail to the following address:

Office of Education
Division of Cancer Epidemiology and Genetics
National Cancer Institute
6120 Executive Blvd., MSC 7242
Bethesda, MD 20892-7242
E-mail: ncidceged-r@mail.nih.gov
Telephone: 301-594-3005
Fax: 301-402-3256

FIRST NAME:	LAST NAME:	E-MAIL:
Check here if you are a participant in the NIH National Graduate Student Research Festival (October 11-12, 2007)

EDUCATION:
1.	Degree:	Choose Degree PhD MD ScD DDS DVM MS MPH MA BA BS	Other:
	Major:	Choose Major Epidemiology Biostatistics Genetics Statistics	Other:
	Institution:			Year:
	Dissertation or Thesis Subject:
2.	Degree:	Choose Degree PhD MD ScD DDS DVM MS MPH MA BA BS	Other:
	Major:	Choose Major Epidemiology Biostatistics Genetics Statistics	Other:
	Institution:			Year:
	Dissertation or Thesis Subject:
3.	Degree:	Choose Degree PhD MD ScD DDS DVM MS MPH MA BA BS	Other:
	Major:	Choose Major Epidemiology Biostatistics Genetics Statistics	Other:
	Institution:			Year:
	Dissertation or Thesis Subject:

RESEARCH INTERESTS: (Listed below are 136 topics of interest divided into 9 headings. Choose no more than five topics total. You may select multiple topics under the same heading by holding the CTRL key to make your selection. )
1.	Biomarkers
2.	Biostatistics	Genetics Survival Clinical trials Methodology Quantitative risk assessment Exposure assessment Early detection Other
3.	Epidemiology	Cancer epidemiology Clinical epidemiology Environmental epidemiology Epidemiologic methods Descriptive epidemiology Genetic epidemiology Molecular epidemiology Nutritional epidemiology Occupational epidemiology Reproductive epidemiology Pharmacoepidemiology Radiation epidemiology Viral epidemiology Women’s health Other
4.	Exposure Assessment	Occupational exposures Environmental exposures Geographic information systems Exposure assessment methods
5.	Cancer Sites	All Cancers Childhood cancers Biliary tract Bladder Bone Brain Breast Buccal cavity Cervix (uterus) Colon/rectum Endometrium (uterus) Endocrine glands Esophagus Eye Gall bladder Hodgkin’s disease Kidney Larynx Leukemia Lip Liver Lung/pleura Melanoma Multiple myeloma Nasal cavity Non-Hodgkin’s lymphoma Ovary Pancreas Pharynx Prostate Salivary gland Skin Stomach Testis Thyroid Vagina Other
6.	Disease and Conditions as Cancer Risk Factors	Allergies Alzheimer's Arthritis Asthma Bacterial infections Birth defects Blood diseases Chlamydia Gallstones Genetic diseases HIV infection and AIDS Human papillomavirus Human T cell lymphotropic virus I and/or II Immune system diseases Infectious diseases Infertility Metabolic syndrome Obstructive lung disease Parasitic diseases Parasitic infection Respiratory tract disease Retroviruses Rickettsial infections Sexually transmitted diseases Tropical diseases Tuberculosis Urinary tract disease Viral infections other than HIV
7.	Health Disparities	Ethnicity Immigrant status Migrant workers Race Socio-economic status
8.	Risk Factors	Adolescence Aging Agricultural chemicals Alcohol Antenatal events/exposures Behavioral factors Cardiovascular disease Diet Dietary supplements Drug abuse Environment/Environmental exposures Ethnicity and race Gallstones Gene-environment interactions Genetic susceptibility Industrial chemicals Nutrition Hormones Immigrant health Immune disorders Inflammation Insulin resistance Metabolic syndrome Obesity Occupational exposures Pesticides Physical activity and fitness Pharmaceuticals Pollution-air Pollution-water Race and/or ethnicity Radon Radiation-ionizing Radiation-solar Socioeconomic level Substance abuse Tobacco Other
9.	Genetics	Genetic epidemiology Clinical genetics Population genetics Family studies

RESEARCH EXPERIENCE: (Summarize up to five of your most important research positions. Use bullets and abbreviations. Be brief.)
1.	Position Title:
	Institution:		Year Started - Year Ended:
	Brief description: (300 char. max.)
2.	Position Title:
	Institution:		Years:
	Brief description: (300 char. max.)
3.	Position Title:
	Institution:		Years:
	Brief description: (300 char. max.)
4.	Position Title:
	Institution:		Years:
	Brief description: (300 char. max.)
5.	Position Title:
	Institution:		Years:
	Brief description: (300 char. max.)

PUBLICATIONS/Abstracts and Presentations: (List up to five of your most important publications)
	Total # publications: Total # abstracts: Total # presentations:
1.	Title/Subject:
	Journal:		Year:
2.	Title/Subject:
	Journal:		Year:
3.	Title/Subject:
	Journal:		Year:
4.	Title/Subject:
	Journal:		Year:
5.	Title/Subject:
	Journal:		Year:

HONORS/AWARDS:
1.	Title of award:		Year:
2.	Title of award:		Year:
3.	Title of award:		Year:

ANALYTICAL SKILLS: (List specialized analytical skills)
	Contingency Tables Linear Regression ANOVA Logistic Regression	Survival Analysis Proportional Hazards Other
COMPUTER SKILLS: (List specialized computer skills other than word processing)
	SAS SPSS STATA	EpiInfo Other
LABORATORY SKILLS: (List major laboratory skills - if applicable)
	Serology ELISAs Mass Spectrometry	Chromatography PCR Other

REFERENCES: (List three references who are knowledgeable about your research skills and experience. They may be asked to write letters on your behalf)
1.	Name:
	Title:
	Organization:
2.	Name:
	Title:
	Organization:
3.	Name:
	Title:
	Organization:

HOW DID YOU LEARN ABOUT THIS FELLOWSHIP?
	Choose Method Journal Ad Advisor Professor Professional Meeting Current DCEG Fellow Current DCEG Scientist DCEG Web Site Other Web Site (specify) Other (specify)	Other: