IDEA Abstract Research Award As an organization, the AC Forum is working to increase awareness and promote diversity in our leadership, membership, and programming. As part of this initiative, AC Forum is pleased to offer scholarships to our National Conference to support the ongoing education of clinicians from underrepresented racial and ethnic groups.Scholarships will be awarded to candidates who best illustrate the desire to further their professional knowledge in the field of antithrombotic therapy. Additional Information If applying for a scholarship, please do not register for the event until after the award notification date. Notification of awards will be given prior to the deadline for early registration. Prior scholarship winners will be considered only after all other applicants. Applicants may apply for both the Conference Scholarship and the Abstract Research Scholarship, however, they will only be selected for one award. Incomplete applications will not be considered. We encourage you to promote the program through social media outlets prior to and during the event, as well as share the information learned with colleagues at your institution. _______________________________________________________ ABOUT THE ABSTRACT RESEARCH AWARDAward recipients will be invited to present their research as a poster presentation at the AC Forum National Conference. They will also receive guidance from a member of the Anticoagulation Forum to assist with preparing their research presentation.Abstracts do not need to be completed in order to apply for the Research Award. Applicants will need to submit an abstract title, 1-2 sentence description, and a statement on why this work is important to the field. Eligibility: Applicants must be clinicians from underrepresented racial and ethnic groups conducting any research within the field of antithrombotic therapy. OR A clinician conducting research on racial health disparities. Scholarship Award: Complementary registration to National Conference (minimum $345 value) Travel stipend of $1500 to cover transportation and lodging (lodging arrangements must be made at the conference hotel)* *Individuals must attend the conference in-person to receive the travel stipend The Anticoagulation Form 16th National Conference will take place in San Francisco, CA on October 28th-30th, 2021. APPLICATIONS DUE JUNE 10, 2021 OK Question Title * 1. Contact Information: First Name: Last Name: Degree: Position: Institution/Clinic: Email Address: OK Question Title * 2. Address: Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Country Phone Number OK Question Title * 3. Race/Ethnicity:Which categories best describes you? Hispanic, Latinx or Spanish Origin - e.g. Mexican, Mexican American, Puerto Rican, Cuban, Salvadorian, Dominican, etc. White - e.g. German, English, Irish, Italian, Polish, etc. Native Hawaiian or other Pacific Islander - e.g. Native Hawaiian, Samoan, Chamorra, Tongan, Fijian, etc. American Indian or Alaska Native - e.g. Navajo Nation, Mayan, Aztec, Blackfeet Tribe, Nome Eskimo Community, etc. Asian - includes all individuals who identify with one or more nationalities or ethnic groups originating in the Far East, Southeast Asia, or the Indian subcontinent Middle Eastern or North African - e.g. Lebanese, Iranian, Egyptian, Syrian, Moroccan, etc. Black or African American - e.g. African American, Jamaican, Ethiopian, Haitian, etc. Some other race, ethnicity, or origin OK Question Title * 4. Abstract Title: OK Question Title * 5. Abstract Description (1-2 Sentences) OK Question Title * 6. How will your research impact the field of anticoagulation? (i.e. Why is this work important)? OK Question Title * 7. Personal Statement:In 300 words or less, please explain why you want to attend the AC Forum National Conference and describe what you would take away from the experience. OK DONE
