Resident Research Grant Application

Resident Information

Please complete this section as the resident submitting the grant.

First Name

Last Name

Credentials (MD, DO)

Name of Residency Program

Year in Residency

Mailing Address

City

State

Zipcode

Research Project Title

Amount of Funding Requested (up to $3,000)

Faculty Preceptor Information

Please complete this section with the faculty preceptor’s information. The preceptor need not be within the Department of Emergency Medicine, but should have appropriate research experience.

Faculty Preceptor Name

First Name

Last Name

Preceptor Credentials (MD/DO)

Preceptor’s Place of Employment

Preceptor’s Title

Preceptor’s Email

Preceptor’s Phone Number

Preceptor’s Address

City

State

Zipcode

Required Grant Information

Please upload the information requested in each section. If you have issues uploading the documents, please contact us at exec@mnacep.org

Resident CV

Maximum file size: 516MB

File must be a Word document (.doc or .docx) or PDF.

Preceptor CV

Maximum file size: 516MB

File must be a Word document (.doc or .docx) or PDF.

Letter of Support from Faculty Preceptor

Maximum file size: 516MB

File must be a Word document (.doc or .docx) or PDF.

Protocol Synopsis (Please provide all required information in the protocol synopsis as outlined on the resident research grant page.)

Maximum file size: 516MB

File must be a Word document (.doc or .docx) or PDF.

Additional Information: please upload additional information here if you would like it included for consideration of your research grant application.

Maximum file size: 516MB

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