First Name *

Last Name *

Gender Identity

Female Male Transgender Female / Trans Woman Transgender Male / Trans Man Non - Binary / Genderq Other Prefer Not to Answer

Preferred Pronouns

He/Him/His She/Her/Hers They/Them/Their Other Prefer Not to Answer

Ethnicity

Hispanic or Latinx. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Not Hispanic or Latinx

Prefer Not to Answer

Race

American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American. A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Prefer Not to Answer

Other

Institution/Organization *

Address Line 1 *

Address Line 2

City *

State *

Enter required value

Postal Code *

Country *

Enter required value United States Canada Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo Democratic Republic of Cook Islands Costa Rica Coted Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island and Mc Donald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isleof Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea Democratic Peoples Republic Korea Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands British Virgin Islands US Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Sark

Email *

Phone *

Primary Mentor Information *

First & Last Name *	Institution *	Email *	Phone *
				Del

Add row

Additional Mentor Information (Optional)

First & Last Name	Institution	Email	Phone
				Del

Add row

Proposed Research Title *

The following materials must be submitted as a single PDF in the order listed below. *

1. Candidate information (0.5 page limit)

• Discuss future career goals and how this award will help achieve these goals

2.  Proposal (2 page limit, excluding references) – be sure to clearly state the question being answered by this project 

• Applicant’s name and project title in the header
• A statement of hypotheses and specific aims, or if performing a quality improvement study, SMART aim (including measures)
• Research or quality improvement approach, including methods, analysis plan, and power/sample size considerations, as appropriate.

3. Project timeline – specify milestones for project completion and what portion will be presented at the ASP conference (0.5 page limit)

4. Letter of support/commitment from primary research mentor

• Comment on applicant’s potential success as a researcher and/or future leader in pediatric antimicrobial stewardship and feasibility of project plan/timeline

5. Applicant’s CV

6. Mentor’s CV

20MB max