Award for Young Investigators in Dermatology - Nomination Form

Eligible candidates include individuals currently in accredited dermatology residency programs or those who have completed their residiencies within the previous two years. (Research must be performed during dermatology training.)

Due: September 30, 2012

Nominee Information
First Name
Last Name
Title / Degree	MD MD/PhD DO
Institution Name
Institution Country	United States Canada
Institution Address 1
Institution Address 2
Institution City
Institution State/Province	Aargau Acre Aguascalientes Alabama Alagoas Alaska Alberta Amapá Amazonas Appenzell Ausserrhoden Appenzell Innerrhoden Arizona Arkansas Bahia Baja California Norte Baja California Sur Basel-Landschaft Basel-Stadt Bern British Columbia California Campeche Ceará Chiapas Chihuahua Coahuila Colima Colorado Connecticut Delaware District of Columbia Distrito Federal Distrito Federal Durango Espírito Santo Florida Fribourg Geneva Georgia Glarus Goiás Graubünden Guanajuato Guerrero Hawaii Hidalgo Idaho Illinois Indiana Iowa Jalisco Jura Kansas Kentucky Louisiana Luzern Maine Manitoba Maranhão Maryland Massachusetts Mato Grosso Mato Grosso do Sul Mexico State Michigan Michoacan Minas Gerais Minnesota Mississippi Missouri Montana Morelos Nayarit Nebraska Neuchâtel Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador Nidwalden North Carolina North Dakota Northern Territory Northwest Territories Nova Scotia Nuevo Leon Nunavut Oaxaca Obwalden Ohio Oklahoma Ontario Oregon Pará Paraíba Paraná Pennsylvania Pernambuco Piauí Prince Edward Island Puebla Quebec Queretaro Quintana Roo Rhode Island Rio de Janeiro Rio Grande do Norte Rio Grande do Sul Rondônia San Luis Potosi Santa Catarina São Paulo Saskatchewan Schaffhausen Schwyz Sergipe Sinaloa Solothurn Sonora South Australia South Carolina South Dakota St. Gallen Tabasco Tamaulipas Tennessee Texas Thurgau Ticino Tlaxcala Tocantins Uri Utah Valais Vaud Veracruz Vermont Virginia Washington West Virginia Western Australia Wisconsin Wyoming Yucatan Yukon Zacatecas Zug Zurich
Institution Postal Code
Phone
Fax
Email
Nominator Information
First Name
Last Name
Title / Degree	MD MD/PhD DO
Institution Name
Institution Country	United States Canada
Institution Address 1
Institution Address 2
Institution City
Institution State/Province	Aargau Acre Aguascalientes Alabama Alagoas Alaska Alberta Amapá Amazonas Appenzell Ausserrhoden Appenzell Innerrhoden Arizona Arkansas Bahia Baja California Norte Baja California Sur Basel-Landschaft Basel-Stadt Bern British Columbia California Campeche Ceará Chiapas Chihuahua Coahuila Colima Colorado Connecticut Delaware District of Columbia Distrito Federal Distrito Federal Durango Espírito Santo Florida Fribourg Geneva Georgia Glarus Goiás Graubünden Guanajuato Guerrero Hawaii Hidalgo Idaho Illinois Indiana Iowa Jalisco Jura Kansas Kentucky Louisiana Luzern Maine Manitoba Maranhão Maryland Massachusetts Mato Grosso Mato Grosso do Sul Mexico State Michigan Michoacan Minas Gerais Minnesota Mississippi Missouri Montana Morelos Nayarit Nebraska Neuchâtel Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador Nidwalden North Carolina North Dakota Northern Territory Northwest Territories Nova Scotia Nuevo Leon Nunavut Oaxaca Obwalden Ohio Oklahoma Ontario Oregon Pará Paraíba Paraná Pennsylvania Pernambuco Piauí Prince Edward Island Puebla Quebec Queretaro Quintana Roo Rhode Island Rio de Janeiro Rio Grande do Norte Rio Grande do Sul Rondônia San Luis Potosi Santa Catarina São Paulo Saskatchewan Schaffhausen Schwyz Sergipe Sinaloa Solothurn Sonora South Australia South Carolina South Dakota St. Gallen Tabasco Tamaulipas Tennessee Texas Thurgau Ticino Tlaxcala Tocantins Uri Utah Valais Vaud Veracruz Vermont Virginia Washington West Virginia Western Australia Wisconsin Wyoming Yucatan Yukon Zacatecas Zug Zurich
Institution Postal Code
Phone
Fax
Email
Research Information
Title of Research Project
Type	Basic Research Clinical Research
Description
Explain briefly the reason for the investigations and how the project was developed: (100 words or less)
Objectives and purpose of the Research (100 words or less)
Methods used (100 words or less)
Results derived (200 words or less)
Conclusions reached (200 words or less)
Describe briefly how the research project has benefited the specialty of dermatology (100 words or less)
Collaborators & Funding
Please note: If external collaborators or sources of external funding represent any perceived  or actual conflict of interest with AAD and its mission, the AAD reserves the right to exclude the nominee from consideration.
Please list any collaborators in this project
Was the research funded by any external sources	Yes No
If yes, name the funding source
Attached Documentation
Supplemental materials should relate directly to the questions in this form.
Narrative Description	A two page, double-spaced narrative description of the nominee's research, including appropriate reference list.
Letter of Recommendation	One letter of recommendation from either the department chair or the faculty advisor.
Brochure	A brochure or brief, one-page description of the residency program.
Curriculum Vitae	Applicant's abbreviated CV (not to exceed four pages)
Other	Optional documentation
Other	Optional documentation