The LE&E Center Clinical Research Leadership Program Application

Applicant Name

Name of Applicant*

First Middle Last Credentials

Eligibility Requirements:

Are you a current ACG member in good standing?*

In which year did you complete your advanced fellowship training?*

Are you able to attend the in person course on June 6 – 8, 2025 in Washington, DC?*

Yes
No

Applicant Background Information

Gender*

Female
Male
Other
Prefer not to answer

How would you describe your race?*

How would you describe your ethnicity?*

Email (Preferred)*

Mobile Phone*

Twitter Handle / Social Media Identifiers (enter N/A if unavailable)*

How did you hear about the Clinical Research Leadership Program?*

Did you apply to the CRLP last year?*

Yes
No

What other leadership programs have you attended or applied to?*

Please also provide the year.

Professional Information

Name of Institution or Practice*

Practice Type

If you selected "Other" for Practice Type in the previous question, please describe your practice setting, or write N/A if this does not apply:*

Title/Position*

Work Location*

City State ZIP Code

Preferred Area of Specialty #1*

Preferred Area of Specialty #2

Applicant Experience Statements

1. Have you acted as a Principal Investigator or Co-Principal Investigator in your research funding?*

Yes
No

2. If you answered 'yes' to question #1, please list the grants for which you have recently served as Principal Investigator Co-Investigator (including title, grant award type, award year, and funding amount).*

Maximum 50 words.

3. Do you have current research funding? Please describe. What research applications are you working on (i.e. type of funding support you are seeking)?*

Minimum 200 words.

4. Have you held ACG funding in the past? If so, what type of grant and when? Did you complete the aims of that grant? If not, what leadership challenges did you have in completing that grant?*

Minimum 200 words.

5. Please list any grants you have received from the College (include year and grant category):*

6. Please list any past or current federal funding you have received (include grant type and year).*

7. Please list your leadership within the College (committees, speaking roles, etc.)*

8. Could you please describe your past/current research leadership experiences?*

Minimum 200 words.

9. What is an example of a research leadership challenge where you felt ill-equipped or unprepared?*

Minimum 200 words.

10. What is a research leadership challenge that you are currently facing?*

Minimum 200 words.

11. What is an example of a successful research leadership accomplishment?*

Minimum 200 words.

12. What research leadership skills are you hoping to develop with this program?*

Minimum 200 words.

Statement of Interest*

Maximum 500 words.

Nominator

Name of your nominator*

Name of individual nominating you for the ACG Clinical Research Leadership Program, i.e. a Supervisor or Mentor who can speak to your research leadership potential and research experience

First Last

Is the nominator an ACG Member?*

What is the name of the nominator's Institution or practice?*

What is the nominator's title?*

Nominator's email address:*

Required Uploads

Upload proof of recent or ongoing funding as a PI or Co-PI – award letter/notice of award listing PI or Co-PI*

must be in word or PDF format

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Upload your current NIH biosketch (must use NIH format)*

Must be in word or PDF format, and use the form: grants.nih.gov/grants/forms/biosketch.htm

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Upload a letter of nomination*

Please note the NEW format for the letter of nomination – use the form found at the top of this page or on the CRLP web page. The format has changed from the standard narrative to 3 focused questions to be completed by the nominator. The nominator should be a clinical chief, research mentor or department chair who can speak to your research leadership potential and research experience.

Accepted file types: pdf, doc, docx, Max. file size: 50 MB.

Upload a headshot (photo)*

For successful applicants, this will be shared with your fellow Clinical Research Leadership Program cohort, along with your contact information, prior to meeting in March.

Accepted file types: jpg, jpeg, tif, , Max. file size: 50 MB.

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