PRIDE Application Form

We are currently accepting applications for Cohort 11.

Choose the primary PRIDE program to which you will apply:

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

Courtesy title:

First name:

Middle name:

Last name, family name, or surname:

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

Home street address (1):

Home street address (2):

City:

State / Territory:

State / Territory:

Zip code:

Cell phone (optional):

Home phone:

Do you have a LinkedIn Account?

If so, what is your account name?

What is your sex?

Citizenship:

Specify other:

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

Which of the following represent your Hispanic origin or ancestry?

(Check all that apply.)

What race do you consider yourself to be?

(Check all that apply.)

Which Native Hawaiian and / or Pacific Islander group?

(Check all that apply.)

Specify other:

Which Asian group?

(Check all that apply.)

Specify other:

Do you have a disability?

Which disability do you have?

(Check all that apply.)

Specify other:

If special accommodations are required, please specify:

Do you come from a disadvantaged background?

Check all that apply for disadvantaged status:

The primary goal of the PRIDE program is to train junior faculty who have an interest in broadening the demographic profile of biomedical research in the heart, lung, blood and sleep domains. Please provide a statement indicating how your background may contribute to this goal and have a potential positive impact in equity and social justice issues in these domains of human health and health care. (5,000 character limit)

Institution of PRIMARY faculty appointment:

PRIMARY department:

What is your PRIMARY faculty rank?

Specify other:

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

Date of PRIMARY faculty appointment:

Institutional street address (1):

Institutional street address (2):

City:

State / Territory:

Click for List of states' and territories' abbreviations

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

Zip code:

Work phone:

Institutional email address:

Alternate email address:

Do you have an Administrative Assistant?

Administrative Asst. name:

Administrative Asst. phone:

Administrative Asst. email address:

Have you ever been supported on a research grant?

If Yes, specify funding entity and type of grant:

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.

Grant mechanism:

Grant # for R01:

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

Grant # for other R-type grant mechanism:

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

Grant # for other program grant mechanism:

Specify other grant mechanism:

Grant # for other grant mechanism:

Are you CURRENTLY funded on a K Award?

Grant type:

Grant #:

Start date (mm):

Start date (yyyy):

End date (mm):

End date (yyyy):

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

Grant type:

Grant #:

Start date (mm):

Start date (yyyy):

End date (mm):

End date (yyyy):

Do you have an NIH grant application currently pending?

Grant Type:

Projected Start Date:

Anticipated Notice of Award Date:

Do you have an eRA Commons username?

eRA Commons username:

ORCID ID:

ORCID ID Requirement

Research field - Type of Research:

(Check all that apply.)

Specify other:

Research field - Topics of Interest:

(Check all that apply.)

Specify other:

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)

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

Please describe your referral source in more detail:

Name of previous PRIDE or SIPID scholar

Additional questions or comments:

Highest degree earned:

Specify other:

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

Year degree awarded (yyyy):

Name of Institution:

Major field of study:

Enter another degree?

Type of degree:

Specify other:

Type of Bachelor's degree:

Specify other:

Type of Master's degree:

Specify other:

Type of Doctorate degree:

Specify other:

Type of Medical degree:

Specify other:

Name of Institution:

Year degree awarded (yyyy):

Major field of study:

Enter another degree?

Type of degree:

Specify other:

Type of Bachelor's degree:

Specify other:

Type of Master's degree:

Specify other:

Type of Doctorate degree:

Specify other:

Type of Medical degree:

Specify other:

Name of Institution:

Year degree awarded (yyyy):

Major field of study:

Enter another degree?

Type of degree:

Specify other:

Type of Bachelor's degree:

Specify other:

Type of Master's degree:

Specify other:

Type of Doctorate degree:

Specify other:

Type of Medical degree:

Specify other:

Name of Institution:

Year degree awarded (yyyy):

Major field of study:

Enter another degree?

Type of degree:

Specify other:

Type of Bachelor's degree:

Specify other:

Type of Master's degree:

Specify other:

Type of Doctorate degree:

Specify other:

Type of Medical degree:

Specify other:

Name of Institution:

Year degree awarded (yyyy):

Major field of study:

Enter another degree?

Type of degree:

Specify other:

Type of Bachelor's degree:

Specify other:

Type of Master's degree:

Specify other:

Type of Doctorate degree:

Specify other:

Type of Medical degree:

Specify other:

Name of Institution:

Year degree awarded (yyyy):

Major field of study:

Please indicate whether or not you wish to waive your right to access the recommendation submitted by your current DEPARTMENT CHAIR:

Please indicate whether or not you wish to waive your right to access the recommendation submitted by your COLLEAGUE OR MENTOR:

Clinical practice:

Research:

Teaching:

Other Effort Allocated (specify):

Specify Other Effort Allocated:

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE in the following areas:

1) Biostatistics (use of software packages)
2) Broadly defined Interprofessional Health Sciences
3) Expertise in Lung related conditions or Obstructive Sleep Apnea with an interest in Health Disparities impact
4) Expertise in Health Disparities and Translational Science with Interest in Lung Related Conditions and Obstructive Sleep Apnea

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE in the following areas:

1) Biostatistics (use of SPSS)
2) Biological Sciences
3) Health Disparities Research

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE in the following areas:

1) Genetics, Epidemiology, Implementation Science, Global Health, Data Science / Biostatistics, or Other Crosscutting Topics

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE in the following areas:

1) Biostatistics and Epidemiology (use of SPSS)

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE in the area of Functional and Translational Genomics of Blood Disorders.

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE in Cardiovascular Sciences.

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE in the following areas:

1) Biostatistics (use of software packages)
2) Obesity Research
3) Obesity-related health disparities across the lifecourse

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE including the following areas:

1) Health disparities research
2) Cardiovascular and pulmonary diseases in minority communities
3) Community-engaged approach in research

Click Upload PDF document at right to attach a summary of your academic and/or work and research EXPERIENCE including the following areas:

1) Bioinformatics/biostatistics
2) Omics of lung diseases, e.g. asthma, pulmonary fibrosis, pulmonary hypertension
3) Dataset mining
4) Translational research
5) Molecular biology/genetics

Click Upload PDF document at right to attach a summary of your research INTERESTS in the fields of Acute Lung Injury, Acute Respiratory Distress Syndrome, Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, Asthma, Pulmonary Hypertension, Pulmonary Fibrosis Sarcoidosis. Outline your professional goals and suggest topics or issues you may want to explore as part of the Advanced Respiratory Research for Equity (AIRE).

Click Upload PDF document at right to attach a summary of your research INTERESTS in the field of Behavioral and Sleep Medicine (BSM). Outline your professional goals and suggest topics or issues you may want to explore as part of the program.

Click Upload PDF doc at right to attach a summary of your research INTERESTS with a focus on cardiovascular and other heart, lung, blood, and sleep disorders.

Outline your professional goals (Max 500 words). Suggest topics or issues you may want to explore or skill sets you would like to improve that relate to your research goals in cardiovascular disease. Such topics may include Genetics, Epidemiology, Implementation Science, Global Health, Data Science/Biostatistics, or other crosscutting topics.

Click Upload PDF document at right to attach a summary of your research INTERESTS in the field of Cardiovascular Health-Related Research (CVD) and health disparities research. Outline your professional goals and suggest topics or issues you may want to explore as part of the program.

Click Upload PDF document at right to attach a summary of your research INTERESTS in the field of Cardiovascular Sciences Research for the Future Faculty of Cardiovascular Sciences (FOCUS). Outline your research accomplishments and future plans, your goals for the program and a list of potential research mentors and local collaborators.

Click Upload PDF document at right to attach a summary of your research INTERESTS in the field of Functional and Translational Genomics of Blood Disorders (FTG). Outline your professional goals and suggest topics or issues you may want to explore as part of the program.

Click Upload PDF document at right to attach a summary of your research INTERESTS in the fields of obesity or obesity-related health disparities across the life course which are related to Obesity Health Disparities (OHD) . Outline your professional goals and suggest topics or issues you may want to explore as part of the program.

Click Upload PDF document at right to attach a summary of your research INTERESTS in the fields of impact of ancestry and/or gender when studying omics of lung diseases. Outline your professional goals and suggest topics or issues you may want to explore as part of your research project and potential mentors and collaborators. If you have experience in any/all of the following areas, please include a summary that describes your academic and/or work and research in a separate paragraph.

1) Bioinformatics/biostatistics
2) Omics of lung diseases, e.g. asthma, pulmonary fibrosis, pulmonary hypertension
3) Dataset mining
4) Translational research
5) Molecular biology/genetics

Click Upload PDF document at right to attach a summary of your research INTERESTS in the field of Research in Implementation Science for Equity (RISE). Outline your professional goals and suggest topics or issues you may want to explore as part of the program. Include specifics on the following areas:

1) possible projects
2) local mentors
3) local collaborators

Use the checklist at right to insure that you have completed all items required for your application.

Please note that your application cannot be considered complete until your documents listed above have been uploaded and your letters of support/recommendation have been received.

Additional questions or comments: