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PRIDE Cohort 9 Pre-Application Form

Returning?

A A A

Please complete the survey below.

Thank you!

Select cohort:

* must provide value

(Cohort 9) 2021-2022

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Current date:

* must provide value

M-D-Y

Choose the primary PRIDE program to which you will apply:

CVD, RISE, FOCUS, and OHD are full and no longer accepting pre-applications. If you wish to apply next year email your information to tmgauzy@wustl.edu

There is a rolling deadline for pre-applications. However, pre-applications received before March 31, 2021 will be prioritized.

* must provide value

Advanced Respiratory Research for Equity (AIRE)

Behavioral and Sleep Medicine (BSM)

Cardiovascular Disease Comorbidities, Genetics, and Epidemiology (CVD-CGE)

Cardiovascular Health-Related Research (CVD)

Future Faculty of Cardiovascular Sciences (FOCUS)

Functional and Translational Genomics of Blood Disorders (FTG)

Impact of Ancestry and Gender On Omics of Lung Diseases (AGOLD)

Obesity Health Disparities (OHD)

Research in Implementation Science for Equity (RISE)

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Choose any other PRIDE program(s) in which you are interested. (Check all that apply.)

Advanced Respiratory Research for Equity (AIRE)

Behavioral and Sleep Medicine (BSM)

Cardiovascular Disease Comorbidities, Genetics, and Epidemiology (CVD-CGE)

Cardiovascular Health-Related Research (CVD)

Future Faculty of Cardiovascular Sciences (FOCUS)

Functional and Translational Genomics of Blood Disorders (FTG)

Impact of Ancestry and Gender On Omics of Lung Diseases (AGOLD)

Obesity Health Disparities (OHD)

Research in Implementation Science for Equity (RISE)

Courtesy title:

First name:

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Middle name:

Last name, family name, or surname:

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Other names under which you have published:
(lastname, firstname middlename; example: Kennedy, John Fitzgerald)

Home street address (1):

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Home street address (2):

City:

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State / Territory:
[Format: 2 letter abbreviation -
Click for List of states' and territories' abbreviations]

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Zip code:

* must provide value

Cell phone:

* must provide value

Home phone:

Do you have a LinkedIn Account?

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Yes

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If so, what is your account name?

What is your sex?

* must provide value

Male

Female

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Citizenship:

* must provide value

Specify other:

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Do you consider yourself Hispanic / Latin(o/a)?

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Yes

Declined

Don't know

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Which of the following represent your Hispanic origin or ancestry?

(Check all that apply.)

* must provide value

Puerto Rican

Dominican (Republic)

Mexican / Mexican American

Cuban / Cuban American

Central / South American

Other Latin American

Other Hispanic or Latin(o/a)

Declined

Don't know

What race do you consider yourself to be?

(Check all that apply.)

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American Indian / Alaska Native

Asian

Black / African American

White

Native Hawaiian / Pacific Islander

Declined

Don't know

Which Native Hawaiian and / or Pacific Islander group?

(Check all that apply.)

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Native Hawaiian

Guamanian

Samoan

Other Pacific Islander (specify)

Declined

Don't know

Specify other:

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Which Asian group?

(Check all that apply.)

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Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian (specify)

Declined

Don't know

Specify other:

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Do you have a disability?

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I have disability

I don't have disability

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Which disability do you have?

(Check all that apply.)

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Physical

Auditory

Visual

Cognitive

Other (specify)

Declined

Specify other:

* must provide value

If special accommodations are required, please specify:

Do you come from a disadvantaged background?

* must provide value

Yes

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To qualify as disadvantaged you must meet two or more of the following criteria. (Check all that apply)

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Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act

Were or currently are in the foster care system, as defined by the Administration for Children and Families

Were eligible for the Federal Free and Reduced Lunch Program for two or more years

Have/had no parents or legal guardians who completed a bachelor's degree

Were or currently are eligible for Federal Pell grants

Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child

Grew up in one of the following areas: a) a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural Health Grants Eligibility Analyzer or b) a Centers for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage Areas

Justification of disadvantaged status:

If you wish to attach a statement below please write N/A in the text box here.

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Expand

You may upload a statement on why you qualify for disadvantaged status here:

Upload file

Institution of PRIMARY faculty appointment:

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PRIMARY department:

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What is your PRIMARY faculty rank?

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Specify other:

* must provide value

WARNING
You must have a faculty-level appointment PRIOR TO the start of the Summer Institute Program (June - August; dates vary by program) to be eligible for the PRIDE Programs. Your Department Chair will be asked to provide a letter documenting your appointment.

Will / Do you have a faculty appointment prior to the Summer Institute?

* must provide value

Yes

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Date of PRIMARY faculty appointment:

* must provide value

M-D-Y

Institutional street address (1):

* must provide value

Institutional street address (2):

City:

* must provide value

State / Territory:
[Format: 2 letter abbreviation -
Click for List of states' and territories' abbreviations]

Zip code:

* must provide value

Work phone:

Institutional email address:

* must provide value

Alternate email address:

Do you have an Administrative Assistant?

* must provide value

Yes

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Administrative Asst. name:

Administrative Asst. phone:

Administrative Asst. email address:

Have you ever been supported on a research grant?

* must provide value

Yes

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If Yes, specify funding entity and type of grant:

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Have you ever been a Principal Investigator (PI) on an NIH-funded grant?

Follow this link for NIH definition of Principal Investigator.
Click browser "Back" button to return to this form.

* must provide value

Yes

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Grant mechanism:

* must provide value

R01

Other R-type Grant (R21, R25, etc.)

Other Program Grant (P30, U01, etc.)

Other Grant Mechanism (specify)

Grant # for R01:

* must provide value

Specify other R-type grant mechanism (e.g., R21, R25, etc.):

* must provide value

Grant # for other R-type grant mechanism:

* must provide value

Specify other program grant mechanism (e.g., P30, U01, etc.):

* must provide value

Grant # for other program grant mechanism:

* must provide value

Specify other grant mechanism:

* must provide value

Grant # for other grant mechanism:

* must provide value

Are you CURRENTLY funded on a K Award?

* must provide value

Yes

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Grant type:

* must provide value

Grant #

* must provide value

Start date (mm):

* must provide value

Start date (yyyy):

* must provide value

End date (mm):

* must provide value

End date (yyyy):

* must provide value

Are you CURRENTLY funded on any other training grant or career development award (R25, T32)?

* must provide value

Yes

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Grant type:

* must provide value

Grant #

* must provide value

Start date (mm):

* must provide value

Start date (yyyy):

* must provide value

End date (mm):

* must provide value

End date (yyyy):

* must provide value

Do you have an NIH grant application CURRENTLY pending?

* must provide value

Yes

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Grant Type:

* must provide value

Project start date:

* must provide value

M-D-Y

Anticipated Notice of Award date:

* must provide value

M-D-Y

Do you have an eRA Commons username?

* must provide value

Yes

reset

eRA Commons username:

* must provide value

ORCID ID:

ORCID ID Requirement

* must provide value

Research field - Type of Research:

(Check all that apply.)

Basic Science

Behavioral

Clinical

Epidemiology

Genetics

Health Disparities

Dissemination and Implementation

Methodology

Statistics

Other (specify)

Specify other:

* must provide value

Research field - Topics of Interest:

(Check all that apply.)

* must provide value

Cardiovascular / Heart

Lung

Blood

Sleep

Other (specify)

Specify other:

This PRIDE Training Program is funded by NHLBI. Your research field must be related to Heart, Lung, Blood or Sleep Disorders.

Please provide a brief description of your current and future research interests, and how this program can facilitate your research study. (Space limit of 5,000 characters)

* must provide value

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PRIDE will offer an opportunity to compete for Small Research Projects (SRP) acting as pilot grants to generate preliminary data for developing NHLBI grant applications. Please give a brief overview of your research plans to take advantage of this opportunity. Describe how your SRP will incorporate the NHLBI research focus on heart, lung, blood, or sleep disorders. (Space limit of 5,000 characters)

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Highest degree earned:

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Specify other:

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Preferred Credentials
e.g., Jane Smith, PhD, RN

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Year highest degree awarded (yyyy):

* must provide value

Please name file as shown below:
Last name followed by First Initial [no spaces]_file name_yyyy-mm-dd

Examples ...
George Washington's CV:
WashingtonG_CV_2019-03-01

Abraham Lincoln's Biosketch:
LincolnA_Biosketch_2019-03-01

Attach your Curriculum Vita in pdf form to your application by clicking Upload document at right:

* must provide value

Upload file

If you have a Biosketch (not required), please upload your most recent version in pdf form by clicking Upload document at right:

If you don't have a Biosketch and would like to create one, please use the template for new format found in this NIH link.

Your optional Biosketch may be sent later to the PRIDE CC BIOSTAT-pridecc@email.wustl.edu

Upload file

Please tell us how you learned about the PRIDE Summer Institute Program?

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Please describe your referral source in more detail:

Name of previous PRIDE or SIPID Scholar

Additional questions or comments:

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You can save your application and return to it later by clicking "Save and Return Later" instead of the "Submit" button. You will be provided with a validation code to recover the saved pre-application from where you left off.

Please be sure to copy and save the validation code.

If you have questions during completion or after your pre-application has been submitted, please email them to the PRIDE Coordination Core.

Please PRINT a copy for your records before you submit your pre-application. To PRINT a copy, Use File / Print from the browser menu at the top, select Adobe pdf as the printer type, click OK; then choose the location where you wish to save this document, name it, and click Save.

Submission of this form allows the PRIDE CC to contact you for additional information regarding your application and career development.

When you are ready, click the Submit button below to send us your pre-application.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.