T32: PINNACLE Program Application

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Required format:

I3nuRanJpnBdBPj4FNTFTAy4wjHr5kF25Hb9ts6H7we8d2WZABCxkhnNGI59HabboHJsjv49JU4A8ua

Please complete the pre-application below.

Make sure to answer all required questions. If you are unable to complete it in one sitting, please scroll down to the bottom and click on "Save and Return Later". The next page will prompt you to NOTE your RETURN CODE and provide your EMAIL so that a link to your entry will be emailed to you, and you can use the return code to pick up where you left off. If you do not have the return code, you will have to start this application over.

Thank you!

Training Coordinator: click on the file below. It is a PDF of all saved survey responses for this instrument. This field is hidden. You still need to scroll all the way down and save the summary, statement, and transcript individually.

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Title:

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Last, Family, or Surname:

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First Name

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Middle Initial:

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Current Mailing Address

Number and Street:

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City:

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State or Foreign Country:

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Zip Code:

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Permanent Mailing Address

Number and Street:

City:

State or Foreign Country:

Zip Code:

Institutional Mailing Address

Current Position/Title:

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Department/Academic Institution:

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Number and Street:

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City:

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State or Foreign Country:

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Zip Code:

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Email Address:

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Current Day Phone:

Current Evening Phone:

Business Fax:

Permanent Phone Number:

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Highest Degree Earned

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PhD

MD, PhD

MD, MPH

MPH

Sc.D

Other

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Please specify other highest degree earned:

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Year, or expected year, of Degree:

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Date of Birth:

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M-D-Y

(Place of Birth) City:

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(Place of Birth) State or Foreign Country:

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Citizenship Status:

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Are you a citizen or permanent resident of the United States?

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Yes

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Gender:

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Male

Female

Other

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Please specify other gender identity:

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What is your race?

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Alaska Native

American Indian

Asian

Black or African-American

White/Caucasian

Native Hawaiian/Pacific Islander

Other

Please specify your race:

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Are you of Hispanic/Latino ethnicity/origin?

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Yes

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Do you have a disability?

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Yes

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Please describe your disability:

Please list all colleges and universities attended, beginning with current or most recent institution. Please use the following formatting when providing your attended colleges and universities in the text box below.

1. Name of institution
2. Dates from and to (M-D-Y)
3. Major Field of Study
4. Name of Degree
5. Date awarded or expected

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[Research Field] Type of research:

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Basic Science

Clinical

Health Disparities

Other

Please specify other type(s) of research:

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[Research Field] Topics of interest:

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Cardiovascular

Lung

Blood

Sleep Disorders

Stroke

Other

Please specify other topic(s) of interest:

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Have you ever applied for and received grant funding?

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Yes

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Are you currently funded on a training grant or career development award (e.g. R25, T32, or K-award)?

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Yes

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eRA Commons username:

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Name/Title of Department Chair

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Department/Institution

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City and State

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Phone Number

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Email Address

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The Family Education Rights and Privacy Act of 1974 and its amendments guarantee students access to educational records concerning them. Applicants are also permitted to waive their right of access to recommendations. This form is used to help reach decisions on admission. Please indicate below whether or not you waive your right of access to the recommendation.

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I DO WAIVE my right to inspect the contents of the recommendation

I DO NOT WAIVE my right to inspect the contents of the recommendation

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Signature

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Add signature

Date of Signature

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M-D-Y

Attach your Curriculum Vitae:

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Attach your most recent Biosketch:

Please note: make sure to include "CURRENT SPONSOR" in your Biosketch. If you do not have a Biosketch, please click on the following link to create one to upload for this application: https://grants.nih.gov/grants/forms/biosketch.htm

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Attach a summary of your academic, work, and/or research experience in these areas:

1. Research methods and biostatistics (e.g., use of SPSS)
2. Biomedical and behavioral sciences
3. Behavioral interventions
4. Health disparities research

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Attach a statement of research interest:

Describe on one separate page your current and future research interests, as well as your research interest in cardiovascular/sleep research. Outline your professional goals , suggest the topics or issues you may want to explore as part of the program, and explain how this program can facilitate your research study.

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Attach a copy of your transcript:

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How did you learn about our T32: PINNACLE program?

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Do you have any questions or comments you would like to share?

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Once you submit this application, you will be prompted to save a copy of it for your records. If you have any questions or concerns about this application, please email them to our training and education faculty lead Dr. Debbie Chung: dxc1729@miami.edu

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.