HTN Mentor Application Form
Council on Hypertension Advisory and Mentoring Program (CHAMP)
Name
First Name
Last Name
Degree(s):
Current Position/Title
How long at the above position (number of years)
Institution
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Age (Optional)
Gender (Optional)
Are you a member of a racial or ethnic group underrepresented in science? (Optional):
Type option 1
Type option 2
AHA Membership Number
AHA Council Membership (please check all that apply):
3CPR (Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation)
ATVB (Council on Arteriosclerosis, Thrombosis and Vascular Biology)
YoungHearts (Council on Lifelong Congenital Heart Disease and Heart Health in the Young)
BCVS (Council on Basic Cardiovascular Sciences)
CVSA (Council on Cardiovascular Surgery and Anesthesia)
QCOR (Council on Quality of Care and Outcomes Research)
CLCD (Council on Clinical Cardiology)
PVD (Council on Peripheral Vascular Disease)
CVSN (Council on Cardiovascular and Stroke Nursing)
HTN (Council on Hypertension)
KCVD (Council on The Kidney in Cardiovascular Disease)
CVRI (Council on Cardiovascular Radiology and Intervention)
EPI (Council on Epidemiology and Prevention)
LCH (Council on Lifestyle and Cardiometabolic Health)
GPM (Council on Genomic and Precision Medicine)
Stroke Council
Curriculum Vitae
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Current clinical and/or research activities, and professional experience
Mentee expertise or other preferences:
Areas of expertise (Hypertension):
Aging
Aldosterone and Adrenal Mechanisms
Angiotensin Converting Enzymes
Blood Pressure Monitoring
Brain Mechanisms
Cardiac Hypertrophy and Dysfunction
Cardiovascular-Renal Interactions
Cerebrovascular Disease and Stroke
Chronic Kidney Disease
Clinical Studies and Trials
Diabetes
Endothelial Function
Epidemiology
Experimental Models
Gender Differences
Genetics, Gene Therapy and Proteomics
Hormones & Natriuretic Factors
Hypertension: Clinical
Hypertension: Experimental
Inflammation, Immunity and Cytokines
Novel Therapeutic Approaches
Nutrition and Hypertension
Obesity and Metabolic Syndrome
Oxidative Stress
Peripheral Neural Mechanisms
Pregnancy and Preeclampsia
Prorenin and (Pro)renin Receptor
Receptors and Signal Transduction
Renal Hemodynamics & Renovascular Hypertension
Renal Tubular Transport
Renin-Angiotensin System
Resistant Hypertension
Salt and Hypertension
Vascular Biology
Vascular Remodeling and Dysfunction
Vascular Stiffness
Areas of expertise (Kidney in Cardiovascular Disease):
Cardiorenal Physiology/Pathophysiology
Receptor Pharmacology
In what other areas do you have expertise (check all that apply)?
Becoming a supervisor
Career development
Communications
Developing a successful clinical hypertension practice center
Effective mentoring relationships
Grant planning and writing
Internationalization
Interpersonal skills
Management of expectations
Managing people
Negotiation
Personal effectiveness
Presentation skills
Publications and CV development
Researcher development
Scientific independence
Scientific Integrity
Time management
Work/Life Balance
I commit to the participation requirements listed in the program description and will fulfill my duties as a mentor to the best of my abilities.
Agree
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