main application form.doc

American Heart Association, Founders AffiliateMartin B. Leon/Johnson & Johnson Cordis Corporation Interventional Cardiology Award

PROJECT SUMMARY

1. Applicant

:

First Middle Last Jr/Sr/etc Degree(s)

2. Institution where work will be done:

3.Sponsor(if applicable) :

First Middle Last Jr/Sr/etc. Degree(s)

4.Department Head: :

First Middle Last Jr/Sr/etc.

5. Applying to: Founders Affiliate

6. Award program: Leon/Johnson & Johnson Cordis Corp. Interventional Cardiology Award

7. Resubmission?

Yes No Previous Application ID #:

8. Dates of proposed award:

Start:

End:

mm/dd/yyyy mm/dd/yyyy

9. Project title (limit to 50 characters or less):

10. Project summary (must be completed on this page):

11. Amount Requested: Year 1 Year 2 Year 3 Year 4Year 5

PROJECT PERSONNEL/SIGNATURES

1. Other professional personal associated with the project:(List name, degree and position of each professional associated with the project, with indication of capacity, e.g., Consultant, Collaborating Investigator, Other Professional, Technician, etc. See instructions for definitions of roles.)

Name & Degree Institution Position Title Role in Project% of Time

First: Last: Degree:







2. SignaturesThe undersigned have reviewed this application for an American Heart Association clinically applied research award and are familiar with the conditions, policies and objectives of the AHA concerning research support and accept the obligation to comply with all such conditions, policies and objectives of the supporting Heart Association.

Applicant (Please Type) Signature Date

Sponsor (If Applicable) Signature Date

Department Head (Please Type)

Institution which assumes fiscal responsibility

Official signing for applicant institution Signature Date

Applicant’s Name (Please Type)

APPLICANT INFORMATION

Current Address

1. Applicant: First Middle Last Degree(s)

2. E-mail address:

3. Department:

4. Division:

5. Institution:

6. Address:

7. Address: 8. City:

9. State: Zip code: Country:

10. Phone Number: Fax:

Institution where work will be done Place an X here and do not complete if same as current address

11. Department:

12. Division:

13. Institution:

14. Address:



18. Phone Number: Fax: Effective Date:

19. Applicant’s present title:

20. Applicant’s present academic position:

21. Applicant’s title at award activation:

22. Applicant’s academic position at award activation: Intern

23. Career stage:

APPLICANT INFORMATION (continued)

24. First full-time faculty/staff appointment: mm/yyyy

25. First full-time faculty/staff appointment at assistant professor (or equivalent) level: mm/yyyy

26.1st doctoral degree: Date earned: mm/yyyy

27. Specialty ( 1st degree): mm/yyyy

28. 2nd doctoral degree: Date earned: mm/yyyy

29. Specialty (2nd degree):

30. If you have not received a doctoral degree, please indicate:Date (mm/yyyy)

Date of actual or expected completion of required course work:

Date of actual or expected admission to doctoral degree candidacy:

31. For Postdoctoral Fellowship applicants only, indicate length of postdoctoral research training or experience (exclusive of clinical training) as of award activation date: yrs mos

32. Indicate total annual grant support available to the applicant, exclusive of salary /fringe and indirect costs:

33. Please indicate any of the following awards you have received or currently hold:

ACS Clinical Research Training Grant for Junior Faculty Leukemia & Lymphoma Society Special Fellow

ACS Research Scholar Grant for Beginning Investigator NIH Career Transition Award (K22)

AHA Scientist Development Grant NIH Independent Scientist Award (K02)

Alzheimer’s Assoc. New Investigator Research Grant NIH Sponsored Clinical Scientist Dev Award (K08)

American Lung Assoc. Career Investigator NIH Research Project Grant (R01)

Arthritis Foundation Investigator Award NIH Senior Scientist Award (K05)

Arthritis Foundation Physician Scientist Dev Award Pfizer Scholar Grant for New Faculty

Burroughs Wellcome Fund Award United Cerebral Palsy Hausman Clinical Scholar Award

Howard Hughes Award Veterans Administration Award

Leukemia & Lymphoma Society Scholar Whitaker Foundation Biomedical Engineering Research Grant

Other Specify

ACS - American Cancer Society AHA – American Heart Assoc. NIH – National Institutes of Health

34.Country of citizenship:

35. Immigration (Status/Visa):

ADMINISTRATIVE INFORMATION

Sponsor Name/Address (complete Sponsor information only if your program requires a Sponsor)

1. Sponsor: First Middle Last Jr/Sr/etc Degree(s)

2. Department:

3. Division:

4. Institution:

5. Address:




10. E-mail address:

Grants Officer Name/Address (Pre-Award)

11. Grants Officer: First Middle Last Jr/Sr/etc

12. Department:

13. Institution:

14. Address:




19. E-mail address:

Fiscal Officer Name/Address (Post-Award)

20. Fiscal Officer: First Middle Last Jr/Sr/etc

21. Department:

22. Institution:


24. E-mail address:

Applicant’s Name (Please type)

ADMINISTRATIVE INFORMATION (continued)

Percent Time

25. Percent of applicant’s total effort devoted to this project:

26. Indicate percent of time applicant spends on:

Project Endorsements

27.Research involves: Yes No

a) Recombinant DNA?

b) Biohazards (other than recombinantDNA)?

c) Human subjects?

d) Adult human stem cells?

e) Human embryonic or fetal stem cells?

f) Human fetal tissue?

g) Cloning?

h) Animal subjects?Date Approved

i) If using animals, is your institution accredited by AAALAC?

Effective date:

j) If using animals, does your institution have a current PHS Animal Welfare Assurance?

ID number:

a) b) and g) -No documentation required

c) and d) -IRB documentation required prior to award activation.

e) and f) -If yes, you are not eligible to apply to the American Heart Association.

h) -IACUC documentation required prior to award activation. (See Application Instructions for details.)

Applicant’s Name (please type)

A. Administration % E. Coursework %

B. Patient care % F. Other %

C. Research %

D. Teaching % G. Total 0%

BIOGRAPHICAL SKETCH (PI)

Do not exceed 5 pages for the complete Biographical Sketch, including bibliography

Name: First Middle Last Jr/Sr/etc Degree(s)

Position/Title:

Education/Training: (Begin with entry into college and include postdoctoral training.)

Institution and Location Dates Attended

Degree (if applicable)

Conferred (mm/yyyy)

Field of Study

For Principal Investigator Only: Address personal variances from ordinary career progression, including part-time work, if applicable.

Positions, Publications and Research Support (create these pages as PDFs)1) Positions/Employment, Memberships and Honors – List in chronological order previous positions, concluding with your present position. Include star/end dates, position title, name of organization and department. Also list other experience and professional memberships, and academic/professional honors received. If necessary senior applicants may list previous employment for the past 15 years and should be very selective regarding memberships/honors. 2) Peer-reviewed Publications – List, in chronological order, selected peer-reviewed publications. Do not include publications submitted or in preparation. 3) Research Support – List selected ongoing or completed (during the last three years) research projects. Give project number, agency, title of project, and dates of award. Then briefly indicate the overall goals of the projects and your role (e.g., PL, Co-Investigator, Consultant) in the research project. Do not list award amounts or percent effort in projects.

CO-AUTHORS/REFERENCES

Co-Authors:Please list each co-author (at assistant professor level or above) with whom you have published an article or abstract within the past 3 years.

Last name First initial Last name First initial Last name First initial

Current Supervisor: First Middle LastDegree(s)

References (if applicable):List names and addresses of persons familiar with your scientific interests and abilities and who have been requested to submit a Reference Report for Applicant. (See application instructions for number of Reference Reports needed and further requirements.)

Name (last name, first name) Title Department InstitutionFirst: Last:

First: Last:

First: Last:

Johnson (SAMPLE) M

RESEARCH PROJECT ENVIRONMENT

FACILITIES: specify the facilities to be used for the conduct of the proposed research. Indicate the performance sites and describe capacities, pertinent capabilities, relative proximity, and extent of availability to the project. Under“Other, “ identify support services and specify the extent to which they will be available to the project. Use continuation pages if necessary.

Location(s):

Computer Support:

Office:

Other:

MAJOR EQUIPMENT: List the most important items already available for this project, noting the location and pertinent capabilities of each.


PROJECT BUDGET Proposed Project Budget Year 1 Year 2

$ Amount $ Amount

1. Salary & Fringe Benefits (Salary)of Investigators/team (Fringe)

2. Project Costs(if allowed for program)

3. Subtotal (lines 1 & 2) $0.00 $0.00

4. Indirect Costs(if allowed by AHA funding component)

5. Total Costs $0.00 $0.00


OTHER SUPPORT

There is no form page for other support. Information on other support should be provided in the format shown below, using blank pages. Include the Principal Investigator’s name at the bottom (right-hand side) and number consecutively with the rest of the application . The sample is intended to provide guidance regarding the type and extent of information requested, If you have no active or pending support, complete an Other Support page with the PI’s name and state “None”

FormatNAME OF INDIVIDUALACTIVE/PENDINGProject number (Principal Investigator)Source

Title of Project (or Subproject)The major goals of this project are…

Dates of Approved/Proposed ProjectAnnual Direct Costs Percent Effort

OVERLAP/ALTERNATIVE (scientific and/or budgetary, summarized for each individual)

ANDERSON, R.R.

ACTIVE

2 RO1 HL 00000-13 (Anderson) 3/1/99-2/28/0230%

NIH/NHLBI $186,529 Chloride and Sodium Transport in Airway Epithelial Cells

The major goals of this project are to define the biochemistry of chloride and sodium Transport in airway epithelial cells and clone the gene(s) involved in transport. 5ROI HL 00000-07 (Baker) 4/1/97-3/31/02

10% NIH/NHLBI $122,717 lon Transport in Fetal Lung

The major goal of this project is to study chloride and sodium transport in normal and cystic fibrosis fetal lung.

PENDING 5 RO1 HL 00000-22 (Anderson) 12/01/99-11/30/01

20% NIH/NHLBI $82,163 Liposome Membrane Composition and Function

The major goals of this project are to define biochemical properties of liposome membrane components and maximize liposome uptake into cells.

ALTERNATIVE There is scientific overlap between aim 2 of NIH HL 00000-22 and aims 3 and 4 of the application under consideration. This application is alternative to the AHA proposal.

FUNDS AVAILABLE (1) - APPLICANTList active or approved awards first, and then list all pending awards.

1. Funding agency: 2. Award name/ID number:

3. Project title:

4. Principal Investigator: 5. Applicant’s role:

6. Beginning date of award: 7. Ending date of award:

8. Award status: Active Approved Pending

9. Total award: 10. Total amt available to applicant:

11. Annual amt available to applicant*: * Do not include applicant’s salary/fringes or intramural support dollars

12a. Is this project overlapping* (current award) or alternative* (pending award) to this AHA proposed project?*scientific or budgetary

Yes No

12b. Whether you answer yes or no, please describe relationship to this AHA project.(See Application Instructions, Funds Available section, for AHA’s definitions and policies regarding Alternative and Overlapping applications. Note: 100% duplication between applications is not a requirement for an application to be deemed alternative or overlapping. The Research Committee may deem an application as alternative or overlapping if there is any duplication of scientific aims or budget.)

(Remember to submit summary/abstract, specific project aims, budget, and budget justification pages for this project with paper sets. See Application Instructions, Enclosures from Applicant section for details.)


3. Project title:







Yes No 12b. Whether you answer yes or no, please describe relationship to this AHA project.

(See Application Instructions, Funds Available section, for AHA’s definitions and policies regarding Alternative and Overlapping applications.Note: 100% duplication between applications is not a requirement for an application to be deemed alternative or overlapping. The ResearchCommittee may deem an application as alternative or overlapping if there is any duplication of scientific aims or budget.)


Applicant’s Name:



3. Project title:







Yes No




3. Project title:










Applicant’s Name:

RESEARCH CLASSIFICATION (1)

The American Heart Association is frequently asked to categorize the research it is funding by a number of different categories. These requests can originate with our donors, the general public or our many volunteers. Please complete each of the following classifications as they relate to your research. The classifications are independent of each other and the classification of your research will not affect the peer review of your application.

CVD/Stroke Classification (select only one)

CVD - related

CVD and closely stroke-related CVD and

broadly stroke-related Closely stroke-related

(see list below) Broadly stroke-related (see list

below)

Current Areas of Interest (If applicable to your project, select one or both. Otherwise leave blank)

To improve population and/or behavioral methods or develop novel methods to advance primary and/or secondary prevention goals of the American Heart Association

To improve the effectiveness of therapy, quality of care and systems of healthcare delivery goals of the American Heart Association.

As a general rule, AHA considers closely related to stroke to include projects involving brain blood vessels, brain tissue, or cerebral ischemia. Projects broadly related to stroke include those involving vascular biology in other vascular beds and coagulation control systems. The following list of stroke terms may assist you:

Closely Related to Stroke Broadly Related to StrokeCerebellum Cerebral infarction Blood pressure controlCerebrovascular disorders Cerebral ischemia Blood vessel growth & development

Carotid artery diseases Cerebral ischemia, transient HypertensionCarotid artery atherosclerosis Subclavian steal syndrome HypoxiaCarotid artery thrombosis Leukomalacia, periventricular Ion channels and blockersCarotid stenos is Vascular headache Intracellular motilityMoyamoya disease Cluster headache Micro-circulation

Cerebral amyloid angiopathy Migraine Platelets & platelet activationCerebral aneurysm Vertebrobasilar insufficiency Smooth muscleCerebral anoxia Dura ThrombosisCerebral arteriosclerosis Echoencephalography TransmitterCerebral arteriovenous malformations Hypothalamus ControlCerebral artery diseases Mid-Brain ReleaseCerebral circulation Neuroglia SynthesisCerebral embolism and thrombosis Neurons Vascular biology

Carotid artery thrombosis Pia Mater; Pia Vein Vascular endotheliumSinus thrombosis Ventricle Vascular injuryWallenberg's syndrome Vascular intema

Cerebral hemorrhage Vascular reactivitiesHematoma, epidural Vascular toneHematoma, subduralSubarachnoid hemorrhage


RESEARCH CLASSIFICATION (2)

Types of Research (select only one)

Basic Biomedical Research is conducted to increase understanding of fundamental life processes.

Clinical Research addresses important questions of normal function and disease using human subjects.

Population Health Research is the science and art of studying the distribution and determinants of health status as influenced by social, economic, and physical environments, human biology, health policy and services and of preventing disease, prolonging life and promoting health at the population level.

Research Categories (select all that apply)

African Americans Imaging

Aging/elderly Medications

Angiogenesis Native Americans

Angioplasty Nutrition

Asian Americans Obesity

Behavioral research Outcomes research

Cholesterol Pediatric research

Diabetes Physical activity/inactivity

Emergency cardiac care/defibrillation/ chain of survival

Rehabilitation

Epidemiological research Smoking/tobacco

Gene therapy Stroke

Heart attack Surgical techniques

Heart failure Transplantation

Heart valves Treatment/patient care

High blood pressure Women

Hispanic/Latino American


SCIENCE CLASSIFICATION (1)

Assignment to a peer review group is based largely upon the Major Science Categories that you choose below (not the sub-categories).

1. Choose two Major Science Categories from those listed below.

2. For each Major Science Category, choose up to six (6) sub -category terms most relevant to your proposal.

NOTE: If you have checked Resubmission on page 1 of your application and the Major Science Classification choices you make are different from your previous submission, your application might not be reviewed by the same scientific peer review committee. With any choice, prior critiques and scores are provided to the new reviewers.

If you make an error or wish to start again, click on the "Reset" button(s) to clear the fields within each group.

Major Science Classification (1)

Sub Classification(s)

Major Science Classification (2)

Sub Classification(s)

2060 - BASIC CELL & MOLECULAR BIOLOGY

2078 Cell Adhesion/Extracellular Matrix3001 Cell Proliferation/Cell Cycle1217 Chromatin, Nuclear Matrix & Mitosis1294 Cytoskeletal Signaling1057 Cytoskeleton & Motility1506 Intracellular Targeting2161 Intracellular Trafficking1815 Muscle Cell Contractility1720 Physical Biochemistry2162 Post Translational Protein Modifications1761 Protein Structure-function Relationships1762 Protein/DNA Interactions1763 Protein/Protein Interactions Including

Contractile Proteins3002 Proteomics1820 Regulation of Gene Expression3003 Stem Cell Biology2064 Structural Biology1814 Structural Studies of Contractile & Other Proteins

1205 - BEHAVIORAL SCIENCE, EPIDEMIOLOGY & PREVENTION

1090 Biomedical Ethics1115 Cardiac Rehabilitation1405 Cost Effectiveness1340 Epidemiology of CVD1355 Exercise/Physical Activity1375 Genetic Epidemiology1400 Health Promotion/Prevention1445 Nutrition2163 Prevention & Management of Diabetes &

Multiple Metabolic Syndrome3004 Prevention & management of Hypertension

1205 - BEHAVIORAL SCIENCE, EPIDEMIOLOGY & PREVENTION

2164 Prevention & Management of Obesity1760 Preventive Cardiology2165 Psycho/Social Factors1795 Quality of Life

2050 - BIOENGINEERING & BIOTECHNOLOGY

2054 Bioelectrics2056 Bioinformatics2057 Biomaterials2058 Biomechanics2166 Biotransport Processes2065 Chemistry & Chemical Synthesis2066 Computation, Modeling & Simulation2167 Computational Systems Biology2067 Defibrillators & Pacemakers2168 Pacing & Devices2059 Drug Delivery2169 Electrophysiology Modeling2060 Image Methods, Analysis & Processing2170 Mechanical Cardiac Assistance &

Replacement Technology2062 Molecular/Cellular Tissue Engineering & Technologies2068 Nanotechnology2069 Non-linear Dynamics (Chaos & Fractals)3026 Rehabilitation Engineering2063 Sensors and Devices2070 Signal Processing & Analysis


1100- BRAIN

3005 Astrocytes1095 Blood-Brain Barrier3006 Brain Immunology & Inflammation3013 CNS Autonomic Control3014 CNS Electrophysiology3007 Cell Therapies in Stroke1195 Cerebral Blood Flow and Metabolism 1200 Cerebral Edema and Intracranial Pressure3011 Cerebral Hemorrhage & Hematoma3008 Cerebral Hypoxia3009 Cerebral Ischemic Pre-conditioning3010 Cerebral Plasticity & Repair1206 Cerebral Vascular Biology3012 Clinical Stroke & Cerebrovascular Disease3015 Epidemiology of Stroke3016 Genetics/Genomics in Brain3017 Mechanisms of Cerebral Ischemic Cell Death3018 Neurodevelopment3019 Neuroprotection: Focal Cerebral Ischemia3020 Neuroprotection: Global Cerebral Ischemia &

Cardiac Arrest3021 Perinatal Brain Injury3003 Stem Cell Biology3022 Stroke Rehabilitation: Clinical & Experimental3023 Technologies in Stroke: MRI, CT, PET, TCD3024 Thrombosis in Cerebrovascular Disease3025 Traumatic Brain Injury

3000 - CARDIAC BIOLOGY/REGULATION

1006 Aging1707 Autonomic Neurophysiology1120 Cardiomyopathies1142 Congestive Heart Failure1276 Coronary Artery Disease1280 Coronary Circulation3033 Developmental Programming of Adult CVD1297 Exercise Physiology1360 Experimental & Clinical Hypertension3031 Gender Differences1415 Hemodynamics1653 Hypertrophy3049 Inflammation1026 Myocardial Apoptosis 1625 Myocardial Ischemia3050 Myocardial Regeneration1024 Myocarditis1828 Neurohumoral Control1661 Nitric Oxide in Myocardial Biology3029 Obesity & Metabolic Syndrome1696 Oxidant Stress1298 Pharmacology2172 Physiological Genomics3032 Pregnancy & Hypertension1826 Remodeling3003 Stem Cell Biology3030 Steroid Hormones1962 Valvular Disease2020 Ventricular Function

3100 - CARDIAC ELECTROPHYSIOLOGY & ARRHYTHMIAS/REGULATION

2173 Ablation2174 Arrhythmia1707 Autonomic Neurophysiology 1190 Cellular Electrophysiology, Voltage-Sensitive Ion Channels2175 Electrophysiologic Testing3040 Heart failure, Cardiomyopathy & Arrythmias2176 Mechanisms of Arrhythmias3039 Non-invasive Risk Stratification2178 Pacing & Devices1298 Pharmacology2177 Physiological Genomics3041 Resuscitation Arrhythmias3003 Stem Cell Biology

1125 - CARDIORENAL

1005 Acid-Base Balance, pH Regulation1006 Aging1707 Autonomic Neurophysiology1171 Cellular & Immunological Mechanisms of Injury3027 Complications of Chronic Kidney Disease1296 Cytokines, Chemokines & Other Mediators3033 Developmental Programming of Adult CVD1248 Diabetic & Hypertensive Vascular Renal Disease1133 Divalent Ion Metabolism & Function1387 Functional Genomics & Proteomics in Renal Disease3031 Gender Differenc es1396 Growth Factors, Peptide Hormones & Autocoids1571 Mechanisms of Renal Progression & Salvage1596 Molecular Genetics of Renal Disease & Development3029 Obesity & Metabolic Syndrome3032 Pregnancy & Hypertension1841 Renal Growth, Differentiation & Angiogenesis3028 Renal Hemodynamics1905 Signal Transduction3003 Stem Cell Biology2073 Steroid & Peptide Natriuretic Factors3030 Steroid Hormones1932 Structural & Matrix Biology1934 Structure Function Correlations in the Kidney1951 Transcriptional & Post-transcriptional Regulation1959 Transporters & Ion Channels

1135 - CARDIOVASCULAR DEVELOPMENT

1150 Cardiovascular Morphogenesis/Teratology1165 Cell Differentiation, Myocyte & Other Lineages1167 Congenital Cardiovascular Disease1285 Coronary/Vascular Development1460 Developing Myocardium - Physiology, Pharmacology,

Metabolism & Disease 1300 Developmental Electrophysiology1461 Developmental Molecular Biology1305 Developmental Physiology/Pharmacology/Metabolism3034 Developmental/Morphogenic Signaling1380 Fetal and Perinatal Circulation2072 Genetic Mapping1435 Human Genetics of Congenital CV Malformations 1600 Molecular Models of Congenital Cardiovascular Malformations1705 Pediatric Cardiovascular Disease1706 Pulmonary Embryology3003 Stem Cell Biology


1175 - CELL TRANSPORT, PHYSIOLOGY & METABOLISM

3038 Biophysics of Ion Channels1110 Calcium & Magnesium Transport & Regulation1169 Cell Biochemistry & Metabolism2202 Cell Membranes1168 Cell Volume Regulation2071 Cellular & Molecular Physiology of Ion Channels1166 Cellular & Molecular Physiology of Ion Transporters1185 Cellular Cardiac Physiology & Pharmacology2201 Cellular Fluorescence Imaging3035 Cellular Vascular Physiology & Pharmacology3036 Epithelial Transport2203 Excitation Cessation Coupling1350 Excitation Contraction Coupling in Muscle Cells2076 Intracellular pH Regulation1585 Mitochondria, Bioenergetics3037 TRP and Store-Ope rated Channels

1475 - IMMUNOLOGY AND MICROBIOLOGY

2186 Autoimmune Diseases2187 Bacteria, Protozoa, Fungi & Viruses1315 Cardiovascular Diseases of Immunogenic Origin 1393 Cytokines2188 Endocarditis & Myocarditis1365 Experimental Organ & Tissue Transplantation1465 Immunochemistry & Immunopathology2189 Immunologic Mechanisms in Cardiovascular Diseases1011 Infectious Diseases of the CV System3043 Inflammatory Molecules (Markers & Mediators) 3042 Innate Immunity1575 Microbial Chemistry1576 Microbial Genetics1577 Microbial Pathogenesis3003 Stem Cell Biology

1530 - LIPOPROTEINS, LIPID METABOLISM & NUTRITION

2190 Animal Models of Lipoprotein Metabolism2191 Atherosclerosis, Lipoprotein-Related Mechanisms3058 Biology of Adipose Tissue3057 Biology of Body Weight Regulation & Obesity3052 Intracellular Cholesterol & Lipid Trafficking3055 Lipid & Lipoprotein Metabolism3056 Lipid & Lipoprotein Oxidation3051 Lipid Efflux & Reverse Cholesterol Transport1515 Lipolytic Enzymes & Lipid Transfer1520 Lipoprotein Receptors and Lipoprotein - Cell

Interactions 1519 Lipoprotein, Structural Biology, Biochemistry &

Biophysics2194 Metabolic Syndrome, Diabetic & other Dyslipidemias 1680 Nutrition, Physical Activity, Lipids & Atherosclerosis3053 Transcription Factors & Regulation of Lipid &

Lipoprotein Metabolism

1540 - LUNG, RESPIRATION & RESUSCITATION

1045 ARDS Acute Respiratory Distress Syndromes & AcuteLung Injury 1015 Alveolar

& Airway Function3059 Alveolar Fluid Clearance1290 CPR (Cardiopulmonary Resuscitation) 1490 Cardiopulmonary Function & Disease2077 Control of Ventilation1415 Hemodynamics1654 Hypoxia & Ischemia3061 Inflammation & Fibrosis1535 Lung Cell & Molecular Biology1580 Microcirculation1597 Molecular Genetics of Lung Disease3060 Neonatal lung1697 Oxidant Metabolism & Signaling

1540 - LUNG, RESPIRATION & RESUSCITATION

1666 Oxygen Transport & Tissue Respiratory Processes1779 Pathophysiology, Cell & Molecular Biology of

Pulmonary Edema2195 Pulmonary Endothelium & Nitric Oxide1780 Pulmonary Hypertension1876 Pulmonary Physiology Pharmacology & Therapeutics1790 Pulmonary Vascular Biology1826 Remodeling2196 Respiratory Genomics & Proteomics1905 Signal Transduction3003 Stem Cell Biology1951 Transcriptional & Post-transcriptional Regulation

1605 - MOLECULAR SIGNALING

2200 Apoptotic Signaling3066 Calcium Signaling3070 Caveolae Microdomains1394 Cytokine Signaling3064 G Protein Coupled Receptors1396 Growth Factors, Peptide Hormones & Autocoids3068 Heterotrimeric G Proteins3067 Junctional Signaling2197 Kinase & Phosphatase Signaling Cascades2198 Nitric Oxide3065 Nuclear Receptors3062 Reactive Oxygen Species3063 Receptor Tyrosine Kinases3069 Rho Family2199 Second Messengers1905 Signal Transduction3003 Stem Cell Biology

1805 - RADIOLOGY & IMAGING

1156 Cardiovascular Ultrasound1806 Computed Tomography2171 Coronary Angiography & Coronary Interventions2074 Echocardiography1455 Imaging Technology1546 MRI, MRA1456 Magnetic Resonance Spectroscopy1457 Myocardial Imaging1671 Nuclear Cardiology1800 Radiology1801 Radionuclide Imaging (PET, SPECT & Others)1807 Vascular Angioplasty & Interventions1994 Vascular Imaging

1940- SURGERY

1025 Anesthesiology1569 Interventions/Surgeries1572 Mechanical Surgical Assistance & Replacement1635 Myocardial Preservation1755 Postoperative Care (Critical Care)1900 Shock3071 Surgery, Cell Therapies1941 Surgery, Congenital Heart Disease1942 Surgery, Ischemic Heart Disease1943 Surgery, Valvular Disease2205 Surgical Outcomes1956 Transplantation, Cardiac1958 Transplantation, Non-Cardiac1975 Vascular Disease


1945- THROMBOSIS

1240 Clotting Factors & Clotting Inhibitors1241 Coagulation1385 Fibrinogen1386 Fibrinolysis1410 Hematology1420 Hemostasis1740 Plasminogen1750 Platelets

3200 - VASCULAR BIOLOGY & BLOOD PRESSURE/REGULATION

1006 Aging3075 Angiogenesis2179 Apoptosis1707 Autonomic Neurophysiology1032 Baroreflex Chemoreflex2017 CNS Control of Cardiovascular Function1276 Coronary Artery Disease1280 Coronary Circulation3033 Developmental Programming of Adult CVD2180 Endothelial Function1297 Exercise Physiology1360 Experimental & Clinical Hypertension3031 Gender Differences1415 Hemodynamics1653 Hypertrophy3049 Inflammation1580 Microcirculation1828 Neurohumoral Control2182 Nitric Oxide3029 Obesity & Metabolic Syndrome1696 Oxidant Stress1298 Pharmacology2184 Physiological Genomics3032 Pregnancy & Hypertension1826 Remodeling1905 Signal Transduction3003 Stem Cell Biology3030 Steroid Hormones2185 Vascular Smooth Muscle Function2010 Vasoactive Agents & Hormones

2000 - VASCULAR WALL BIOLOGY

1035 Angiogenesis & Vasculogenesis1031 Animal Models of Atherosclerosis & Arterial Injury1066 Atherosclerosis, Pathogenesis1056 Cell - Cell Interactions2206 Diabetes/Atherogenic Mechanisms1330 Endothelium Structure and Function1550 Macrophage Biology1910 Smooth Muscle Cells3003 Stem Cell Biology1991 Vascular Cell Apoptosis1970 Vascular Cytokines1980 Vascular Extracellular Matrix & Cell Adhesion1981 Vascular Growth Factors1662 Vascular Reactivity3080 Vascular Wall Developmental2005 Vascular Wall Mechanics

PERSONAL DATA The American Heart Association (AHA) is committed to monitoring the operation of its review and award processes to detect, and the deal with appropriately, any instances of real or apparent inequities with respect to age, gender, race or ethnicity of its applicants. The following information will enable us to honor this commitment.

Upon receipt of the application by the AHA, this form will be separated from the application. The form will not be duplicated, and will not be a part of the review process. Data will be confidential. All analyses conducted on the data will report aggregate statistical findings only and will not identify individuals.

If you decline to provide this information, it will in no way affect consideration of your application. Your cooperation will be greatly appreciated.

1. Applicant: First Middle Last Jr, III, etc

2. Social Security Number: 3. Date of birth:

mm/dd/yyyy4. Gender: Male Female

5. Race and/or ethnic origin (place an X in the most appropriate box):

(Note: For purposes of reporting mixed racial and/or ethnic origins, the category that most closely reflects the individual’s recognition in the community should be used.)

Alaskan NativeA person having origins in any of the original people of North America, and who maintains cultural identification through tribal affiliation or community recognition.

American Indian

AsianA person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent. This area includes, for example, China, India, Japan, Korea, etc.

Pacific Islander A person having origins in any of the original peoples of the islands of the Pacific. This includes people of Polynesian, Samoan or Micronesian heritage.

Black, not of Hispanic Origin A person having origins in any of the black racial groups of Africa.

Hispanic A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

White, not of Hispanic Origin A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

The following information is requested for program evaluation purposes. Data will be reported in aggregate statistical form only.

6. Do you have tenure? Yes No Not Applicable Tenure Year:

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