CHA Health Services Research Academy Inquiry

Thank you for your interest in the Children’s Hospital Association Health Services Research Academy. Please complete the requested information below to apply for enrollment in the Academy.

Your Contact Information

Required

First Name

Last Name

Email

Your Current Employer

Healthcare Facility

Division/Department

Your Current Primary Area of Work:

Are you currently a trainee (e.g., student, resident, fellow, etc)?

Yes
No

Have you ever:

Have you ever:
	Yes	No
Participated in clinical research?	Yes	No
Led a research project?	Yes	No

Which of the following best describes your experience with:

Which of the following best describes your experience with:
	Research	Statistics
Novice	Research	Statistics
Beginner	Research	Statistics
Intermediate	Research	Statistics
Advanced	Research	Statistics

In 1 or 2 sentences, briefly describe the topic of research that interests you the most:

In 1 or 2 sentences, briefly describe your ideas on how to improve care for patients:

In 1 or 2 sentences, briefly describe what research skills you hope to acquire:

If you have a local mentor, please enter their contact information:

First Name

Last Name

Email

Please indicate the level of Academy participation you are interested in:

Required

Tier 1: Research education modules only
Tier 2: Research modules with project coaching
Tier 3: Research modules with full project mentoring, biostatistics, and data support
Tier 4: Group participation in the Academy (e.g., multiple members of a division of hospital medicine)