ATS 2016 Student Scholar Program Participant Survey

PARTICIPANT INFORMATION

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* 1. First Name

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* 2. Last Name:

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* 3. Institution Name:

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* 4. Email Address:

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* 5. I am currently enrolled in

Medical School

Graduate School

Nursing School

Respiratory Therapy School

What year of schooling are you currently enrolled in (i.e. 1st Year of Medical School, 3rd Year of Nursing School)

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* 6. My areas of interest include (check all that apply):

Pulmonary Medicine

Critical Care

Sleep Medicine

Pediatrics

All of the Above

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* 7. I have submitted an abstract for consideration to ATS 2016:

Yes

If yes, abstract ID number(s):

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* 8. Topics of Interest (check all that apply):

Congenital, Genetic and Developmental Lung Diseases

Cystic Fibrosis

Diseases of Air Movement and Air Ways

Asthma

COPD

Bronchiectasis

Diseases of Pleura and Chest Wall

Mesothelioma

Pleural Effusion

Environmental, Exposure-Related and Occupational Lung Diseases

Infectious Lung Diseases

Pneumonia

Pleural Infections

Fungal Lung Diseases

Tuberculosis

Interstitial Lung Diseases

Idiopathic Pulmonary Fibrosis

Lung Cancers

Nonspecific Interstitial Pneumonitis

Sarcoidosis

Lymphangioleiomyomatosis

Pulmonary Vascular Disease

Pulmonary Hypertension

Respiratory Failure

Sepsis

Shock

ARDS

Sleep-Related and Neuromuscular Breathing Disorders

Obstructive Sleep Apnea

Myasthenia Gravis

Systemic Diseases Affective the Respiratory System

HIV/AIDS

By my electronic signature, I attest that the information I have provided here is accurate, and that I agree to:
- Attend at least 2 days of the ATS 2016 International Conference
- Complete a follow-up survey after the ATS 2016 International Conference
- Allow the ATS to contact me to request additional information on the progress of my career for a period of five years following my participation in the ATS Student Scholar Program.

*Please contact Eileen Larsson at elarsson@thoracic.org with any questions*

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* 1. First Name

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* 2. Last Name:

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* 3. Institution Name:

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* 4. Email Address:

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* 5. I am currently enrolled in

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* 6. My areas of interest include (check all that apply):

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* 7. I have submitted an abstract for consideration to ATS 2016:

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* 8. Topics of Interest (check all that apply):

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* 9. Signature: