Fellows Research Day Registration and Abstract Submission Form

Deadline for submission is: April 4, 2022 at 11:59pm

Name *

First Name Last Name

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

Institution/Hospital *

Department *

Work Address 1 *

Work Address 2

City (required) *

State (required) *

Zip Code (required) *

Work Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Work Phone *

work phone

Cell Phone *

cell phone

Work E-mail *

example@example.com

Home Address 1 *

Home Address 2

City (required) *

State (required) *

Zip Code (required) *

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parking Needed? *

Yes No

Note regarding parking: 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 you do have food allergies, please indicate details in the box below (

0/50

Meal Selection *

Chicken Vegetarian Special Request (list below)

Special Meal Request (

0/100

Photography Waiver

**Your registration will not be processed if you do not accept this waiver.**

The American Heart Association (AHA) will take photographs and video during its conference and may display, reproduce and/or distribute them in AHA educational, news or promotional material, whether in print, electronic or other media, including the AHA website. Your registration for an AHA conference is your grant to AHA the right to use your name, image and biography for such purposes as well as any other purpose. All photographs and/or videos become the property of the AHA.

Please check that you accept the Photograph Waiver. *

I accept

Presenting Author *

First Name Last Name

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

E-mail *

example@example.com

Academic position: *

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

(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.)

Institution / hospital *

Type of abstract *

Clinical Basic Undeclared

Preference of abstract presentation: *

Oral Poster Either

Other Authors: (Please provide full name, submitting Fellow's name goes first)

#1 Presenting Author

First Name Last Name

#2 Other Author

First Name Last Name

#3 Other Author

First Name Last Name

#4 Other Author

First Name Last Name

#5 Other Author

First Name Last Name

#6 Other Author

First Name Last Name

#7 Other Author

First Name Last Name

#8 Other Author

First Name Last Name

#9 Other Author

First Name Last Name

#10 Other Author

First Name Last Name

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) *

First Name Last Name

Mentor email address *

example@example.com

There is a character/word limit of 1950 character or appox. 350 words total for the abstract

Abstract Title (< 250 characters) *

0/250

Background *

Hypothesis *

Methods *

Results *

Conclusions *

If you would like to attach a figure or table, please do so here. Files can be no larger than 3MB

What question would you like to ask Dr. MacRae?