Framingham Heart Study (FHS) Committee Nominee Form Framingham Heart Study Committee Nominee Form Deadline: June 24, 2022 Nominee Name* First Last Degree (if applicable) Nominator Name(s), if any:Please separate multiple names with a comma.Committee(s) being nominated for:* Executive Committee (EC) Framingham Investigator Steering Committee (FAISC) Ancillary Proposal Review Committee (APRC) Committee first choice:Please indicate your top preference for placement on available committees.(choose one)Ancillary Proposal Review Committee (APRC)Framingham Investigator Steering Committee (FAISC)Executive Committee (EC)Committee second choice:Please indicate your second preference for placement on available committees.(choose one)Ancillary Proposal Review Committee (APRC)Framingham Investigator Steering Committee (FAISC)Executive Committee (EC)Committee third choice:Please indicate your third preference for placement on available committees.(choose one)Ancillary Proposal Review Committee (APRC)Framingham Investigator Steering Committee (FAISC)Executive Committee (EC)Would you like to attach a Curriculum Vitae or resume?* Yes No CV/Resume FilePDF files preferredMax. file size: 100 MB.Academic rank, if any: Professional title(s)/position(s):* Clinical practice focus, if known: Research focus, if known: Primary institution affiliation:* Name of institution: City location of institution: State/province of institution: Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Prior FHS committee membership?* Yes No If yes, names of committee(s):If yes, any committee leadership experience? Yes No If yes, any other relevant notes:Prior non-FHS committee membership?*Note: prior committee service to mention can be for professional societies, other cohort studies, clinical trials, etc. Yes No If yes, any committee leadership experience? Yes No If yes, any other relevant notes:Prior involvement in FHS research?* Yes No If yes, involved through publications only? Yes No If yes, involved through grants? Yes No If involved through grants, as PI or Co-PI? Yes No Please note any special experiences with participant contact, lab specimen, or data analysis work:If yes, involved through other activities? Yes No If yes, any other relevant notes:Members representing scientific domains of increased interest will be appointed as needed by NHLBI. Please check all that apply to the nominee:* Current or recently expired FHS ancillary study PI Interested in Co-chair of APRC or FAIC Cardiologist Epidemiologist Geneticist/omics expert Data scientist Neurologist Early Career Investigator Other Other* Note: feel free to add pages and/or include attachments if you need more space when providing answers to above Drop files here or Select files Max. file size: 100 MB.