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Fellows Research Day Registration and Abstract Submission Form

Deadline for submission is: 11:59pm, January 28, 2013

Registration

*First name:

Middle initial:

*Last name:

*Title (i.e. MD, PhD, etc.):

*Institution/Hospital:

*Department:

*Work Address 1:

Work Address 2:

*Work City:

*Work State:
    *Work Zip:

*Work Phone:

*Cell Phone:

*Work Email:

*Home Address 1:

Home Address 2:

*Home City:

*Home State:
    *Home Zip:

*Parking Needed:
Yes No

Note: Only check 'Yes' if you will be traveling from another institution and do not already have parking privileges/arrangements at the University of Pittsburgh.

*Food Allergies:
Yes No

Note: If yes, please indicate details in the box below (<50 words).

*Meal Selection:
Chicken Vegetarian Special Request (list below)

Special Meal Request (<100 words):
Note: We will make every attempt to fill your special request.

Abstract Submission

Presenting Author:

*First name:

Middle initial:

*Last name:

*Title (i.e. MD, PhD, etc.):

*Email Address:

*Academic position:
(Note: Only trainees are eligible to participate in Fellows Research Day. Individuals with a faculty appointment at the instructor level or higher are not eligible.)

Clinical Fellow Medical Student Research Postdoctoral Fellow
Graduate Student Resident Undergraduate Student

Other trainee position (specify, 30 character limit):

*Institution / hospital:

*Type of abstract:

Clinical Basic Undeclared

*Other Authors: (full name in each box, submitting Fellow's name goes first)

1.
2.
3.
4.
5.
6.
7.

Note: The author affirms that the abstract herein will not have been published as a manuscript prior to presentations at the American Heart Association meeting, that any animal studies conform with the "Position of the American Heart Association on Research Animal Use" (circulation 1985; 71:849), and that any human experimentation has been conducted according to a protocol approved by the institutional committee on ethics of human investigation or, if no such committee exists, that it conforms with the principles of the Declaration of Helsinki of the World Medical Association (Clinical Research 1966; 14:103.)

Yes     No

*Mentor (full name):

*Mentor email address:

*Abstract Title (< 250 characters):

*Abstract (< 1950 characters):



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