ࡱ>  Rbjbj 3:bb*<vvFFFFFZZZ8 Z72")()))4+L.T05555555,:J=5F@14+4+@1@15P2FF))D6P2P2P2@1FF)F)5P2@15P2P244.Ζ{145^7H74,>P2,>4P2F4@1@1@155P2@1@1@17,>@1@1@1@1@1@1@1@1@1v :   University of Illinois at Chicago Diabetes, Obesity and Nutrition Research Training Program Application Form Instructions: Please complete this form and submit electronically as a single document or pdf file to: Terry Unterman, M.D. c/o Pamela Terrell, Program Coordinator Section of Endocrinology, Diabetes and Metabolism (M/C 640) Department of Medicine University of Illinois at Chicago 1819 West Polk Street Chicago, Illinois 60612  HYPERLINK "mailto:terrell@uic.edu" terrell@uic.edu 1. Name:  FORMTEXT       2. Gender: 1 FORMCHECKBOX  Male 2 FORMCHECKBOX  Female 3. Address:  FORMTEXT       City, State, Zip:  FORMTEXT       4. Telephone: (Office)  FORMTEXT       (Home)  FORMTEXT       5. Email:  FORMTEXT       6. Availability date:  FORMTEXT       7. Citizenship: 1 FORMCHECKBOX  U.S. Citizen or Noncitizen National Non-U.S. Citizen 2 FORMCHECKBOX  With a Permanent U.S. Resident Visa ( Green Card ) 3 FORMCHECKBOX  With a Temporary U.S. Visa If not a U.S. citizen, of which country are you a citizen?  FORMTEXT       8. Permanent Mailing Address  FORMTEXT        FORMTEXT        FORMTEXT       E-mail:  FORMTEXT       9. Are you Hispanic (or Latino)? 1 FORMCHECKBOX Yes 2 FORMCHECKBOX No 3 FORMCHECKBOX Do not wish to provide. 10. What is your racial background? (Check one or more.) 1 FORMCHECKBOX  American Indian or Alaska Native 1 FORMCHECKBOX  Native Hawaiian or other Pacific Islander 1 FORMCHECKBOX  Asian 1 FORMCHECKBOX  Black or African American 1 FORMCHECKBOX  White 1 FORMCHECKBOX  Other 1 FORMCHECKBOX  Do not wish to provide 11. Do you have a disability? 1 FORMCHECKBOX Yes 2 FORMCHECKBOX No 3 FORMCHECKBOX Do not wish to provide If yes, which of the following categories describe your disability(ies): 1 FORMCHECKBOX Hearing 2 FORMCHECKBOX Visual 3 FORMCHECKBOX Mobility/Orthopedic Impairment 4 FORMCHECKBOX Other 12. Are you from a disadvantaged background? 1 FORMCHECKBOX Yes 2 FORMCHECKBOX No 3 FORMCHECKBOX Do not wish to provide 13. Education: [For predoctoral applicants, please include copies of your undergraduate and graduate school transcripts.] institution, department & location . years attended (from to)degreedate confered (mo/yr)major fieldminor field FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       14. Professional experience: dates (mo/yr)job titlebrief descriptionemployeraddress FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       15. Other relevant experience:  FORMTEXT       16. Professional licensure and board certification: [List type(s) and states of licensure and board certification(s).]  FORMTEXT       17. Professional organizations:  FORMTEXT       18. Scholarly contributions: [List of publications, abstracts, presentations, and other research activities.] 19. Awards: 20. Program track you are applying for: 1 FORMCHECKBOX  Basic Science 2 FORMCHECKBOX  Clinical 3 FORMCHECKBOX  Community/Epidemiology/Behavioral 21. Please provide the following information: a. Thesis research topic and/or other research topic (if relevant):  FORMTEXT       b. Research advisor:  FORMTEXT       c. Residency Training (if applicable): 1. Area of Specialization:  FORMTEXT       2. Institution:  FORMTEXT       3. Postgraduate Year (PGY):  FORMTEXT       22. Provide a brief personal statement describing your specific research interests and reason for pursuing this obesity-prevention training program. (Limit to one page)  FORMTEXT       23. What are your research/career goals and how do you see this research training contributing to these goals?  FORMTEXT       24. Mentor Information: [Indicate the mentor(s) that you are interested in working with. See list of program faculty at the end of this application.] " Primary Research Mentor from Program Faculty:  FORMTEXT       " Co-mentor from Program Faculty:  FORMTEXT       " Academic Advisor (if different from primary and co-mentors):  FORMTEXT       27. References: In evaluating your candidacy, we request that you solicit letters of reference from three individuals acquainted with your academic experience and research work. We are particularly interested in their opinion of your research qualifications and potential for an academic and research career. Please have the letters sent to Dr. Terry Unterman at the address listed on the cover page of this application. Please list the names and addresses of those references you have requested: 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       University of Illinois at Chicago Diabetes, Obesity and Nutrition Research Training Program Faculty Name/Degree(s) Primary (& Secondary) Appointment(s) Research Interest Terry G. Unterman, MDMedicine Endocrinology, Diabetes and Metabolism (Physiology and Biophysics) (Kinesiology and ] Nutrition)Regulation of gene expression and metabolism by insulin and FoxO transcription factorsSteven J. Ackerman, PhDBiochemistry and Molecular Genetics (Medicine)Regulation of gene expressionWaddah Alrefai, MDMedicine GastroenterologyIntestinal transport of lipids and bile acids, gene regulation by insulin and nutritionElena Barengolts, MDMedicine Endocrinology, Diabetes and MetabolismDiabetes and Vitamin D, Glycemic IndexScott T. Brady, PhDHead, Anatomy & Cell BiologyNeurobiology, axon transport, mechanisms of neuropathy, diabetic neuropathyCarol Braunschweig, PhDKinesiology and NutritionBody composition and insulin sensitivity, nutritional intervention, obesity preventionNoel Chavez, PhDCommunity Health Sciences School of Public HealthNutritional evaluation, community assessment of nutritionScott Cotler, MDMedicine Hepatology [\lmno{}~ݸ~sksks~]O>] h+gh/CJOJQJnHtHhbCJOJQJnHtHh/CJOJQJnHtHh/OJQJhhbOJQJhhbOJQJnHtH(hahb5B*OJQJnHphtH+hahb5>*B*OJQJnHphtH)hIhbB*CJOJQJnHphtHhbB*OJQJnHphtH%hahbB*OJQJnHphtH hb5h@n hahb"\mno~{{& 5`0p@ P !$`'0*bx]bgdb-$ ;`0p@ HP !$`'(0*`dh]`a$gdb)$ 5`0p@ P !$`'0*E<]Ea$gdb"gd@n S k zzzzzzX! /`0P !$`'0*-b]bgdan! /`0P !$`'0*-b]bgd/c /`0P !$`'0*-bEƀF]bgd/      ǻǟǎ}l\O=O"jhb>*OJQJUnHtHhb>*OJQJnHtHhlhb5OJQJnHtH hIhbCJOJQJnHtH hjhbCJOJQJnHtH hanhbCJOJQJnHtHhXM=h_c0JOJQJh_ch_cB*OJQJphh_cB*OJQJph jh_cB*OJQJUphhanB*OJQJphh/CJOJQJnHtHh_cCJOJQJnHtH * , sRR! `0(#$`'0*-b#x]b^#`gdb `0b b]bgdb 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hBOvh-CJOJQJ^JaJhBOvh-CJaJhBOvh-5CJ\aJ'hBOvh-5CJOJQJaJnHtH-// 0?0[0y00D;;;;; $Ifgd1kdPm$$If-F! n'J @@@0,6    34-ab pyt1000 1161jaaaa $Ifgd1kdQn$$If-F! n'J0,6    34-ab yt16171J1f11jaaa $Ifgd1kdo$$If-F! n'J0,6    34-ab yt11112-2jaaa $Ifgd1kdo$$If-F! n'J0,6    34-ab yt1-2.2B2_22jaaa $Ifgd1kdap$$If-F! n'J0,6    34-ab yt1222253jaaa $Ifgd1kdq$$If-F! n'J0,6    34-ab yt15363G3a3y33jaaaa $Ifgd1kdq$$If-F! n'J0,6    34-ab yt13333jaaa $Ifgd1kdqr$$If-F! n'J0,6    34-ab yt1Diagnosis, treatment of non-alcoholic steatohepatitis, pathogenesis hepatocarcinomaLuisa DiPietro, DDS, PhDDirector, UIC Center for Wound Healing and Tissue RegenerationStem/progenitor cell biology, tissue repair and regenerationSamuel Dudley, MDMedicine - Cardiology (Physiology and Biophysics)Oxidative stress, stem cell therapy in cardiac diseaseGiamila Fantuzzi PhDKinesiology and Nutrition (Microbiology and Immunology)Leptin, obesity, inflammation, adipocyte biologyMarian Fitzgibbon, PhDMedicine  Institute for Health Research and Policy, School of Public HealthPrevention and behavioral intervention in obesityBen Gerber, MD, MPHMedicine - General Medicine and Endocrinology, Diabetes and MetabolismComputer- and community-based interventions in diabetes and obesityHoward Gordon, MDMedicine  Health Promotion and ResearchHealthcare disparities, doctor-patient communication in diabetes, obesity and chronic diseaseNissim Hay, PhDBiochemistry and Molecular GeneticsAkt kinases, signaling pathways, molecular mechanisms of cancer, aging and diabetes Rhonda Kineman, PhDMedicine  Endocrinology, Diabetes and Metabolism (Physiology and Biophysics)Growth hormone  regulation and function in diabetes, obesity and metabolismTimothy Koh, PhD Kinesiology and Nutrition Inflammation, muscle regeneration, wound healingJames Lash, MDMedicine  NephrologyEpidemiology of diabetes, kidney disease and hypertensionE. Douglas Lewandowski, PhDPhysiology and Biophysics (Medicine)Energy metabolism, lipid and mitochondrial metabolism in heartAyako Makino, PhD Medicine  Endocrinology, Diabetes and MetabolismEndothelial biology, endothelial dysfunction in diabetesAsrar Malik, PhDHead, PharmacologyEndothelial biology, stem cells, cell signalingRobin J. Mermelstein, PhDDirector, Institute for Health Research and Policy Health promotion and preventionAndrew Mesecar, PhDCenter for Pharmaceutical BiotechnologyStructural biology, high throughput screening, sirtuins, oxidative stressRichard D. Minshall, PhDPharmacologyCell signaling, endothelial cell biology and functionJose Oberholzer, MDSurgery, Director of Cell and Pancreas Transplantation (Medicine  Endocrinology, Diabetes and Metabolism, Bioengineering)Pancreatic islet biology and transplantationJohn O Bryan, PhDPharmacologyCell signaling, caveolae, mitogenic signaling pathwaysDale A. Pelligrino, PhDAnesthesiologyRegulation of brain metabolism and cerebral blood flow in diabetesVictoria Persky, MDEpidemiology and Biostatistics School of Public HealthEpidemiology of endocrine modifiers, asthma and diabetes Shane A. Phillips, PhDDepartment of Physical TherapyEndothelial dysfunction in obesity and insulin resistance: impact of diet and exercise.James H. Rimmer, PhDDisability and Human DevelopmentObesity and obesity-related conditions in persons with disabilityLaurie Ruggiero, PhDCommunity Health SciencesDiabetes self-care, community-based health promotion/preventionR. John Solaro, PhDHead, Physiology and BiophysicsCardiac physiology, cardiomyopathy, heart failureZhenyuan Song, PhDDepartment of Kinesiology and NutritionFatty liver disease, alcoholic and NAFLD, in cell culture systems and animal models.Papasani V. Subbaiah, PhDMedicine  Endocrinology, Diabetes and Metabolism (Kinesiology and Nutrition)Lipid metabolism and transport, dyslipidemias, insulin resistanceAngela L. Tyner, PhDBiochemistry and Molecular GeneticsGene expression and cell biology in GI tract and liverMasuko Ushio-Fukai, PhDPharmacology Endothelial biology, oxidative stress and angiogenesis in diabetesYong Zhao, PhDMedicine (Endocrinology, Diabetes and Metabolism) Stem cell biology, beta cell differentiation, circulating islet progenitor cells     UICCOM DON RTP  PAGE 4 of  NUMPAGES 7 Zjaaa $Ifgd1kd!s$$If-F! n'J0,6    34-ab yt1&^jaaaa $Ifgd1kds$$If-F! n'J0,6    34-ab yt1,hjaaaa $Ifgd1kdt$$If-F! n'J0,6    34-ab yt1jaaa $Ifgd1kd1u$$If-F! n'J0,6    34-ab yt1"8jaaa $Ifgd1kdu$$If-F! n'J0,6    34-ab yt18:^ljaaa $Ifgd1kdv$$If-F! n'J0,6    34-ab yt1lnjaaa $Ifgd1kdAw$$If-F! n'J0,6    34-ab yt1Fjaaaa $Ifgd1kdw$$If-F! n'J0,6    34-ab yt1<jaaaa $Ifgd1kdx$$If-F! n'J0,6    34-ab yt1`jaaa $Ifgd1kdQy$$If-F! n'J0,6    34-ab yt1^b@b*D, (H*H,Fp h$0гЧh~CJOJQJh:8jh:8U h2~hbhbOJQJnHtHhBOvCJOJQJ^JaJhBOvh-CJOJQJaJ hBOvh-CJOJQJ^JaJ hBOvh[CJOJQJ^JaJhICJOJQJ^JaJ4`bbjaaaa $Ifgd1kdz$$If-F! n'J0,6    34-ab yt1bd`jaaaa $Ifgd1kdz$$If-F! n'J0,6    34-ab yt1`b jaaa $Ifgd1kda{$$If-F! n'J0,6    34-ab yt1 @jaaaa $Ifgd1kd|$$If-F! n'J0,6    34-ab yt1bjaaa $Ifgd1kd|$$If-F! n'J0,6    34-ab yt1*Djaaa $Ifgd1kdq}$$If-F! n'J0,6    34-ab yt1*jaaa $Ifgd1kd!~$$If-F! n'J0,6    34-ab yt1*,Pjjaaa $Ifgd1kd~$$If-F! n'J0,6    34-ab yt1 (jaaa $Ifgd1kd$$If-F! n'J0,6    34-ab yt1Hjaaaa $Ifgd1kd1$$If-F! n'J0,6    34-ab yt1*jaaa $Ifgd1kd$$If-F! n'J0,6    34-ab yt1Hjaaa $Ifgd1kd$$If-F! n'J0,6    34-ab yt1,jaaa $Ifgd1kdA$$If-F! n'J0,6    34-ab yt1|jaaa $Ifgd1kd$$If-F! n'J0,6    34-ab yt1|~jaaa $Ifgd1kd$$If-F! n'J0,6    34-ab yt18pjaaaa $Ifgd1kdQ$$If-F! n'J0,6    34-ab yt1 hjaaa $Ifgd1kd$$If-F! n'J0,6    34-ab yt1$jaaa $Ifgd1kd$$If-F! n'J0,6    34-ab yt10jaaa $Ifgd1kda$$If-F! n'J0,6    34-ab yt1jYHFFFFF h X`]`gdb h X]gdbkd$$If-F! n'J0,6    34-ab yt1LNPR h X`]`gdb  !r`'gdb "$,.BDFHJLNPR󼸱 h2~hbh:8hb!h_c0JCJOJQJmHnHuhhb0JCJOJQJ%jhhb0JCJOJQJUhhbCJOJQJ1 0:pb/ =!"#$% vDText17tDeCheck4tDeCheck5vDText18vDText19vDText20vDText21vDText22vDText23tDeCheck1tDeCheck2tDeCheck3vDText24vDText25vDText26vDText27vDText28tDeCheck6tDeCheck7tDeCheck8tDeCheck9vDeCheck10vDeCheck11vDeCheck12vDeCheck13vDeCheck15vDeCheck14vDeCheck16vDeCheck17vDeCheck18vDeCheck19vDeCheck20vDeCheck21vDeCheck22vDeCheck16vDeCheck17vDeCheck18$$If!v h#v #v#v#v#v#v#v^#v#v #v #v :V l t0(, 5 555555^55 5 5 / aEkd$$Ifl Z ets!"n( ^ t0(,,,,44 lavDText29vDText30vDText34vDText31vDText32vDText33,$$If!v h#v #v#v#v#v#v#v^#v#v #v #v :V l t0(, 5 555555^55 5 5 / / / / / / / / / / / / / / / / / /  /  /  / aEkd$$Ifl Z ets!"n( ^ t0(,,,,44 lavDText29vDText30vDText34vDText31vDText32vDText33,$$If!v h#v #v#v#v#v#v#v^#v#v #v #v :V l t0(, 5 555555^55 5 5 / / / / / / / / / / / / / / / / / /  /  /  / aEkdV$$Ifl Z ets!"n( ^ t0(,,,,44 lavDText29vDText30vDText34vDText31vDText32vDText33,$$If!v h#v #v#v#v#v#v#v^#v#v #v #v :V l t0(, 5 555555^55 5 5 / / / / / / / / / / / / / / / / / /  /  /  / aEkd%$$Ifl Z ets!"n( ^ t0(,,,,44 lavDText29vDText30vDText34vDText31vDText32vDText33,$$If!v h#v #v#v#v#v#v#v^#v#v #v #v :V l t0(, 5 555555^55 5 5 / / / / / / / / / / / / / / / / / /  /  /  / aEkd,$$Ifl Z ets!"n( ^ t0(,,,,44 lavDText29vDText30vDText34vDText31vDText32vDText33,$$If!v h#v #v#v#v#v#v#v^#v#v #v #v :V l t0(, 5 555555^55 5 5 / / / / / / / / / / / / / / / / / /  /  /  / aEkd4$$Ifl Z ets!"n( ^ t0(,,,,44 la$$Ifl!v h#v#v#v#v#v$ #v#v #v#v :V l t055555$ 55 55 / alkdv8$$Ifl j V zf- '$   t0$$$$44 lalvDText35vDText36vDText37vDText38vDText39$$Ifl!v h#v#v#v#v#v$ #v#v #v#v :V l t0, 55555$ 55 55 / / / / / / / / / / / / / / / / /  alkd=$$Ifl j V zf- '$   t0$$$$44 lalvDText35vDText36vDText37vDText38vDText39$$Ifl!v h#v#v#v#v#v$ #v#v #v#v :V l t0, 55555$ 55 55 / / / / / / / / / / / / / / / / /  alkdC$$Ifl j V zf- '$   t0$$$$44 lalvDText35vDText36vDText37vDText38vDText39$$Ifl!v h#v#v#v#v#v$ #v#v #v#v :V l t0, 55555$ 55 55 / / / / / / / / / / / / / / / / /  alkdI$$Ifl j V zf- '$   t0$$$$44 lalvDText35vDText36vDText37vDText38vDText39$$Ifl!v h#v#v#v#v#v$ #v#v #v#v :V l t0, 55555$ 55 55 / / / / / / / / / / / / / / / / /  alkdP$$Ifl j V zf- '$   t0$$$$44 lalvDText35vDText36vDText37vDText38vDText39$$Ifl!v h#v#v#v#v#v$ #v#v #v#v :V l t0, 55555$ 55 55 / / / / / / / / / / / / / / / / /  alkd?V$$Ifl j V zf- '$   t0$$$$44 lalvDText35vDText36vDText37vDText38vDText39$$Ifl!v h#v#v#v#v#v$ #v#v #v#v :V l t0, 55555$ 55 55 / / / / / / / / / / / / / / / / /  alkdb\$$Ifl j V zf- '$   t0$$$$44 lal$$Ifl!v h#v#v#v#v#v$ #v#v #v#v :V l t055555$ 55 55 / / / / / / / / / / / / / / / / /  alkd7`$$Ifl j V zf- '$   t0$$$$44 lalvDText40vDText41vDText42vDeCheck16vDeCheck17vDeCheck18vDText51$$IfJ!vh#v~$:V l4 t065~$/  aJf4vDText49vDText52vDText53vDText50vDText43vDText44vDText14vDText15vDText16vDText15vDText15vDText15$$If!vh#v] #v#vx :V - 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