TSFRE Research Fellowship Application

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TSFRE Research Fellowship Application
Thoracic Surgery Foundation for Research and Education
633 N. St. Clair Street, 23rd Floor
Chicago, IL 60611
312-202-5868
[email protected]
TSFRE Research Fellowship Application
Deadline: October 15, 2012 11:59 p.m. EST
Application Guidelines: This document is not an online application and cannot be submitted through the
TSFRE website. To use this application, save to your desktop and submit with attachments to
[email protected] All application documents must be submitted together.
*Required fields
General Information
*Title of Project:
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*Duration of Project:
1 Year ☐
2 Years ☐
Individual
*First Name:
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Middle Initial:
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*Last Name:
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Suffix:
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Degree(s):
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*Sex:
Male
☐
Female ☐
*Telephone Number:
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Fax:
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*E-mail Address:
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*Street Address:
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*City:
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*Postal Code: Choose an item.
*State/Province:
*Country:
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Sponsoring Institution
*Institution Name:
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*Your Position at This Institution:
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*Department:
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Attachments
Submit completed application with the following attachments:
*Your Curriculum Vitae (pdf)
*Your Photo (jpeg)
Narrative
*Personal Goals (five sentences or less)
State your personal career goals. Identify exactly what you wish to accomplish in the course of the
proposed work. Logical future studies may be indicated, as well as the potential impact of this work on the
field.
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*Background (500 words)
Provide a highly focused presentation of the background and rationale for this project, a critical
presentation of the most important work of others in the field, and the results of any preliminary work by
the investigators. This page should reflect the applicant’s knowledge and critical analysis of the area of
interest and provide a foundation for the proposed project.
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*Experimental Design (750 words)
State the hypothesis that you will test and the methods that you will use. Indicate the design of the study
and outline in logical sequence how you plan to proceed. Indicate the source of biological material that
you will study and the statistical methods you will use in analyzing your data. Excessive methodologic
detail is unnecessary, unless you are developing or applying new and unique techniques.
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*The Educational Environment (750 words)
Organized contributions of a senior investigator and mentor to the development of the trainee must be
clearly identified. A very specific learning program for the trainee must be identified, and the manner in
which you proposed work will interact with the training program should be well delineated.
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*Pending Research Applications
List any other research applications pending or approved and whether any overlap with another TSFRE
application/request. The intent of TSFRE is to enable the applicant by the award, but not to provide
redundant funding for a funded project. If you have no other pending research applications, enter “none.”
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*Literature References (500 words)
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*Proposed Budget for this Award
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Project Participants
List the first and last names and e-mail addresses of all project participants.
*These fields are required if you have project participants. If you do not, you may leave fields blank.
1. First Name:
Last Name:
E-mail Address:
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2. First Name:
Last Name:
E-mail Address:
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3. First Name:
Last Name:
E-mail Address:
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4. First Name:
Last Name:
E-mail Address:
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5. First Name:
Last Name:
E-mail Address:
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Payee of Award
List the institution that will receive the award check.
*Check should be made payable to:
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*Attention (name):
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*Telephone Number:
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Fax:
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*E-mail Address:
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*Street Address:
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*City:
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*State/Province:
*Postal Code: Choose an item.
Institution Tax ID #:
*Country:
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Chair of the Department of Surgery
This person must be able to attest to your commitment to a career in investigative cardiothoracic surgery.
*Chair Name:
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*Chair E-mail:
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*Letter of Support: Attach Letter of Support pdf with your completed application.
Mentor
*Scientific Mentor Name:
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*Telephone Number:
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*E-mail Address:
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*Letter of Support:
Attach Letter of Support pdf with your completed application.
*Mentor’s CV:
Attach mentor’s CV pdf with your completed application.
Sponsor
Same as Mentor ☐
*Sponsor Name:
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*Telephone Number:
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*E-mail Address:
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*Letter of Support:
Attach Letter of Support pdf with your completed application.
Upload only if your Sponsor is different than your mentor.
Program Director
*Program Director Name:
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*Telephone Number:
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*E-mail Address:
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*Letter of Support:
Attach Letter of Support pdf with your completed application.
Upload only if your Program Director is different than your mentor.
Additional Institutional Funding
Complete this section if you are receiving institutional funding for your research.
Name of official authorized to commit additional institutional support: Choose an item.
*Telephone Number:
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*E-mail Address:
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Amount of institutional funding committed to project:
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Additional Outside Funding
Complete this section if you are receiving additional funds supplied by a funding grant from government,
or an industrial, philanthropic, or charitable institution.
Principal Investigator:
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Grant Title:
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Grant ID#:
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Amount of institutional funding committee to project:
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Miscellaneous
Attach any other relevant data, such as figures, additional letters of support, etc.
Attachments Reminder
*Your Curriculum Vitae (pdf)
*Your Photo (jpeg)
*Chair of the Department of Surgery Letter of Support (pdf)
*Mentor Letter of Support (pdf)
*Mentor’s CV (pdf)
Sponsor Letter of Support (if different than Mentor) (pdf)
Program Director Letter of Support (if different than Mentor) (pdf)
Letter of Support from official authorized to commit additional institutional support (if you are receiving
institutional funding for your research). (pdf)
Other relevant data, such as figures, additional letters of support, etc. (pdf)
Submit all application materials to [email protected] by October 15, 2012 11:59 p.m. EST.
Copyright© 2012 Thoracic Surgery Foundation for Research and Education

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