Candidate Name
Last, First Middle Initial / Gender / Female
Male
Project Title
Limit to 80 characters, incl. spaces
Candidate Degree(s)
CHECK ALL THAT APPLY – Place your cursor on the left side of the box and click twice. A menu will open allowing you to check the box. Please enter year degree was awarded. PhD candidates with more than 7 yrs post degree and MD candidates with more than 7 yrs post-fellowship should seek application approval by the PBF Fellowship Program Scientific Director. / Degree / Year received
M.D. (or equivalent)
Ph.D. (or equivalent)
M.D., Ph.D.
D.V.M.
M.P.H.
Research Type / Basic Science / Is this a reapplication? / Yes / No
Clinical / Human subjects? / Yes / No
Translational / Vertebrate animals? / Yes / No
Candidate Email Address
Candidate’s Telephone
(please give both office and cell numbers)
Candidate Citizenship
CHECK ONLY ONE – Place your cursor on the left side of the box and click twice. A menu will open allowing you to check the box. Fellowships are restricted to citizens and permanent residents of the US and Canada and individuals with US or Canadian permanent residency applications on file. / U.S. citizen
Canadian citizen
Permanent Resident of U.S. or Canada
US or Canadian Permanent Residency Application has been filed prior to application deadline with U.S. or Canadian Immigration Services (documentation of the filing is provided in this application)
Mentor Name
(Last, First Middle Initial)
Mentor Degree(s)
CHECK ALL THAT APPLY – Place your cursor on the left side of the box and click twice. A menu will open allowing you to check the box.) / M.D. (or equivalent)
Ph.D. (or equivalent)
M.D., Ph.D. / D.V.M.
M.P.H.
Mentor Email Address
Sponsoring Institution
Department
Division

PBF Fellowship Application– rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

è Enter project title, Candidate’s name and Mentor’s name in the header and then delete this line.

ABSTRACT

Describe the proposed studies briefly. Do not exceed the space provided (Arial 11-point font size, single-line spacing).

Include the following sections.

Statement of the Problem.
Specific Aims.
Experimental Approach.
Significance of the results.

LAY SUMMARY

Describe the proposed studies in language understandable to non-scientists/physicians, including the relevance of this research to public health. Do not exceed 125 words (Arial 11-point font, single-line spacing).


TABLE OF CONTENTS

PBF Fellowship Application-rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

Page Numbers

PBF Fellowship Application-rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

Face Page (generated from the online application system) 1

Abstract and Lay Summary 2

Table of Contents (not to exceed one page) 3

Budget Page 4

Candidate’s Statement (not to exceed one page) 5

Candidate’s Biographical Sketch (not to exceed four pages) 6-x

Primary Mentor’s Statement (not to exceed three pages) xx-xx

Primary Mentor’s Biographical Sketch (not to exceed four pages) xx-xx

Primary Mentor’s PBF Fellows History xx-xx

Primary Mentor’s Training Record xx-xx

Department Chair’s Letter / Institutional Commitment xx-xx

Other Faculty Mentors xx-xx

Resources (not to exceed two pages) xx-xx

Reapplication Information (not to exceed two pages) xx-xx

Abbreviations (not to exceed one page) xx

------Sections above are not counted in the seven-page limit------

RESEARCH PLAN (Limit of seven pages for A-D below)

A. Statement of Problem and Specific Aims xx-xx

B. Background and Significance xx-xx

C. Preliminary Studies xx-xx

D. Research Design and Methods xx-xx

------Sections below are not counted in the seven-page limit------

Human Subjects xx-xx

Vertebrate Animals xx-xx

Literature Cited (no page limit) xx-xx

Consultant Letters of Support xx-xx

Appendix (optional) xx-xx

Documentation regarding U.S. or Canadian Permanent Residency Application (if applicable) xx-xx

Letters of Recommendation xx

PBF Fellowship Application-rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

è Correct Table of Contents page numbers to correspond to your application, then delete this line.

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PBF Fellowship Application – rev. 10/10

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Mentor’s Name: LAST, First Candidate Name: LAST, First

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PBF Fellowship Application – rev. 10/10

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Mentor’s Name: LAST, First Candidate Name: LAST, First

BUDGET PAGE

This page serves to provide the fellowship funding information and does not require further completion (a budget justification or budget plan) by the applicant.

The total 2010 Parker B. Francis Fellowship Award in direct dollars is as follows:

YEAR 1
JULY 2015 – JUNE 2016
$50,000 / YEAR 2
JULY 2016 – JUNE 2017
$52,000 / YEAR 3
JULY 2017 – JUNE 2018
$54,000 / TOTAL
JULY 2015 – JUNE 2018
$156,000

Award funds are to be used to support salary and benefits for the PBF Fellow and for the fellow’s travel to scientific meetings, up to a maximum of $2,000 per year.

Supplies and equipment purchases are not allowed. These expenses should be supported by the mentor’s research grants. Such grants are an essential part of the application as documentation of sufficient financial support to complete the fellow’s project. Indirect costs on the PBF Fellowship are not allowed.

It is permissible to supplement the PBF stipend with funds from research grants, departmental funds or clinical income provided that clinical duties do not exceed 25 percent effort.

No budget justification or budget plan is required.

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

CANDIDATE’S STATEMENT

(one-page limit, Arial 11-point font size, single-line spacing)

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

BIOGRAPHICAL SKETCH

NAME
/ POSITION TITLE
DEGREE(S)
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)
INSTITUTION AND LOCATION / DEGREE
(if applicable) / YEAR(s) / FIELD OF STUDY

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

A.  Positions and Honors. List in chronological order previous positions, concluding with your present position. List any honors. Include present membership on any Federal Government public advisory committee.

B.  Publications (in chronological order).

PLEASE LIST PUBLICATIONS BY THE FOLLOWING CATEGORIES:

1.  Peer-reviewed articles published or in press

2.  Book chapters

3.  Manuscripts submitted but not accepted at the time of application

4.  Abstracts at national meetings relevant to the application

C.  Research Support. List selected ongoing and pending research projects (federal and non-federal support). Begin with the projects that are most relevant to the research proposed in this application. State the specific aims of the projects and your role (e.g., PI, Co-Investigator, Consultant) in the research project. èInclude effort and annual direct dollar amounts for each research project.

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

PRIMARY MENTOR’S STATEMENT

(three-page limit)

BIOGRAPHICAL SKETCH

NAME
/ POSITION TITLE
DEGREE(S)
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)
INSTITUTION AND LOCATION / DEGREE
(if applicable) / YEAR(s) / FIELD OF STUDY

D.  Positions and Honors. List in chronological order previous positions, concluding with your present position. List any honors. Include present membership on any Federal Government public advisory committee.

E.  Peer Reviewed Publications

èThe mentor should note here their total number of peer-reviewed publications and then list in chronological order all peer-reviewed publications which will fit in the 4-page limit.

F.  Research Support. List selected ongoing and pending research projects (federal and non-federal support). Begin with the projects that are most relevant to the research proposed in this application. State the specific aims of the projects and your role (e.g., PI, Co-Investigator, Consultant) in the research project. èInclude ongoing and pending research support and list effort and annual direct dollar amounts for each research project.

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

PRIMARY MENTOR’S PBF FELLOWSHIP HISTORY

Fellow’s Name: / Dates of PBF Support:
Current Position:
Grant support since completion of PBF Fellowship:
Publications since completion of Fellowship: (list up to six references)
Fellow’s Name: / Dates of Support:
Current Position:
Grant support since completion of PBF Fellowship:
Publications since completion of Fellowship: (list up to six references)

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

PRIMARY MENTOR’S TRAINING RECORD

Training Period / Name
(Last, First) / Degree(s) / Grant Awards Received
(including award year) / Current Position (past trainees)
Source of Support (current trainees) /

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First


OTHER FACULTY MENTORS OR COLLABORATORS

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

RESOURCES

(two-page limit)

Specify the facilities to be used to conduct the proposed research. Indicate the performance sites and describe capacities, pertinent capabilities, relative proximity, and extent of availability to the project. Under “Other,” identify support services (e.g., machine shop, electronics shop) and specify the extent to which they will be available to the project. You may use two pages if necessary.

LABORATORY

CLINICAL

ANIMAL

COMPUTER

OFFICE

OTHER

MAJOR EQUIPMENT

List the most important equipment items already available for this project, noting the location and pertinent capabilities of each.

REAPPLICATION

(two-page limit, Arial 11-point font size, single-line spacing)

Date of previous application:

ABBREVIATIONS

ALI acute lung injury (PaO2/FiO2 < 300 mmHg, with bilateral infiltrates and no cardiac abnormalities)

ARDS acute respiratory distress syndrome; subset of ALI, with PaO2/FiO2 < 200, bilateral infiltrates and no cardiac abnormalities)

AM alveolar macrophage

CD14 membrane pattern recognition receptor involved in LPS recognition

CEA University of Washington Center for Expression Arrays (Roger Bumgarner, PhD, Director)

Fas membrane receptor which activates caspase-dependent pathways

FasL ligand for membrane Fas

Jo2 monoclonal antibody which activates membrane Fas

LBP lipopolysaccharide binding protein; binds and solubilizes bacterial LPS

LPS lipopolysaccharide

MMP(s) matrix metalloproteinase(s)

MMP-3 stromelysin


RESEARCH PLAN

(seven-page limit for items A-D)

A.  STATEMENT OF PROBLEM AND SPECIFIC AIMS

B.  BACKGROUND AND SIGNIFICANCE

C.  WORK ACCOMPLISHED AND PRELIMINARY STUDIES

D. RESEARCH DESIGN AND METHODS


HUMAN SUBJECTS

VERTEBRATE ANIMALS

LITERATURE CITED

CONSULTANTS

PBF Fellowship Application – rev. 4/14

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Mentor’s Name: LAST, First Candidate Name: LAST, First

APPENDIX CONTENTS

APPLICANTS APPLYING FOR U.S. OR CANADIAN PERMANENT RESIDENT STATUS

LETTERS OF RECOMMENDATION

Letters of recommendation are provided from:

1.  John K. Smith, M.D. ()

2.

3.

PBF Fellowship Application – rev. 4/14