Boston-area Biomedical Informatics Research Training Program

Application Form

Application deadline: January 15, 2010

First Name: Last Name: Address: Street City State Please select AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist. of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusetts MichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennessee TexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOther Country Zip Code

Phone: Email: Degrees: Please select MDPhDMD/PhD Other Please upload: (File size less then 2 MB) Letter of Interest*: Curriculum Vitae

*The letter of interest should be a personal statement that describes your goals, computer background, and other relevant experience.

Are there specific areas of Biomedical Informatics in which you are interested?

Electronic Medical Record Systems Bioinformatics Consumer Informatics Public Health Informatics Telemedicine

Medical Imaging Clinical Information Systems Security & Privacy Issues in Informatics Clinical Decision Making Other

Other areas of interest and additional comments:

List the institutions that will send your transcripts to us:

List the names and affiliations of the three references you will have sent to us:

Please tell us where you first heard about this program:

Letters of reference and transcripts to:

Dr. Alexa T. McCray
Director, BIRT Fellowship Program
Center for Biomedical Informatics
Harvard Medical School
10 Shattuck Street
Boston, MA 02115

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