Date of Document ____________ [Listing of all dates should be with oldest (first) to most recent (last)] CURRICULUM VITAE Jane/John G. Doe, M.D., Ph.D. Associate Professor of Medicine (and include Administrative Title) Division of Cardiovascular Medicine 1. HOME ADDRESS: 1234 Mulberry Lane Anytown, WI 53022 (414) 555-1212 2. OFFICE ADDRESS: Medical College of Wisconsin 8701 Watertown Plank Road Milwaukee, Wisconsin 53226 Phone: (414) 555-8888 Fax: (414) 555-9999 E-mail:[email protected] 3. PLACE OF BIRTH: Milwaukee, Wisconsin 4. CITIZENSHIP: U.S.A. 5. EDUCATION: mm/yyyy - mm/yyyy - B.S., University of Wisconsin, Madison, WI mm/yyyy - mm/yyyy - M.D., Medical College of Wisconsin, Milwaukee, WI mm/yyyy - mm/yyyy - Ph.D., Medical College of Wisconsin, Milwaukee, WI 6. POSTGRADUATE TRAINING AND FELLOWSHIP APPOINTMENTS: mm/yyyy - mm/yyyy - Resident, Internal Medicine, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI mm/yyyy - mm/yyyy - Fellowship, Cardiology, Medical College of Wisconsin, Milwaukee, WI mm/yyyy - mm/yyyy - Postdoctoral Fellow, Physiology Medical College of Wisconsin, Milwaukee, WI 7. MILITARY SERVICE: mm/yyyy - mm/yyyy - U.S. Medical Service 8. FACULTY APPOINTMENTS (INCLUDE SECONDARY AND ADJUNCT APPOINTMENTS): mm/yyyy - mm/yyyy - Visiting Scientist, University of Wisconsin Medical School, Madison, WI mm/yyyy - mm/yyyy - Assistant Professor, Department of Medicine, Division of Cardiovascular Medicine, The Medical College of Wisconsin, Milwaukee, WI mm/yyyy - mm/yyyy - Associate Professor, Department of Medicine, Division of Cardiovascular Medicine, The Medical College of Wisconsin, Milwaukee, WI 9. ADMINISTRATIVE APPOINTMENTS: mm/yyyy - mm/yyyy - Senior Associate Dean for Faculty Affairs, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 10. EDUCATIONAL ADMINISTRATIVE APPOINTMENTS: mm/yyyy - mm/yyyy - Director, Cardiovascular Medicine Residency Program, Department of Internal Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 11. HOSPITAL AND CLINICAL ADMINISTRATIVE APPOINTMENTS: mm/yyyy - mm/yyyy - Chief of Staff, Froedtert Memorial Lutheran Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226 12. RESEARCH ADMINISTRATIVE APPOINTMENTS: mm/yyyy - mm/yyyy - Director, Neuroscience Research Laboratory, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226 13. HOSPITAL STAFF PRIVILEGES: mm/yyyy - present Froedtert Memorial Lutheran Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226 mm/yyyy - present St. Joseph's Hospital, 5000 W. Chambers, Milwaukee, WI 53210 14. SPECIALTY BOARDS AND CERTIFICATION: Board Certified Issue Date Expiration American Board of Internal Medicine mm/yyyy mm/yyyy ABIM - Cardiology Certificates Issued By Issue Date Expiration CPR AHA mm/yyyy mm/yyyy ACLS AHA mm/yyyy mm/yyyy Licensure Issue Date Expiration Wisconsin License mm/dd/yyyy mm/dd/yyyy Other State Licenses mm/dd/yyyy mm/dd/yyyy 15. AWARDS AND HONORS: mm/yyyy - Phi Kappa Phi mm/yyyy - Alpha Omega Alpha mm/yyyy - Best Teaching Service Award, The Medical College of Wisconsin 16. MEMBERSHIPS IN HONORARY AND PROFESSIONAL SOCIETIES: mm/yyyy – mm/yyyy - Alpha Omega Alpha Medical Honor Society (President of Chapter) mm/yyyy – mm/yyyy - American Society of Cardiology mm/yyyy – mm/yyyy - American College of Physicians 17. EDITORSHIPS/EDITORIAL BOARDS/JOURNAL REVIEWS: Editorships mm/yyyy - mm/yyyy - Journal of the American College of Cardiology Editorial Boards mm/yyyy - mm/yyyy - Journal of Clinical Investigation Journal Reviews mm/yyyy - mm/yyyy - Journal of Clinical Investigation 18. LOCAL/REGIONAL APPOINTED LEADERSHIP AND COMMITTEE POSITIONS: mm/yyyy - mm/yyyy - Member, Peer Review Committee, AHA Wisconsin Affiliate mm/yyyy - mm/yyyy - Member, Wisconsin Chapter, American College of Cardiology 19. NATIONAL ELECTED/APPOINTED LEADERSHIP AND COMMITTEE POSITIONS: mm/yyyy - mm/yyyy - Member, NIH Study Section, Biomedical Research and Technology mm/yyyy to present - Consultant/Ad Hoc Reviewer, NIH Study Section mm/yyyy - Member, NIH site visit mm/yyyy to present - President, American Physiological Society mm/yyyy to present - Board member, American Association of Medical Colleges 20. RESEARCH GRANTS/AWARDS/CONTRACTS/PROJECTS: A. Active Peer Review Title: Control of the heart Source: NIH Role: Principal Investigator Dates: July 1, 20xx - June 30, 20xx Direct Funds: $1,285,000 (total for all years) Title: Training in Renal Research Source: NIH Role: Co-Investigator Dates: July 1, 20xx - June 30, 20xx Direct Funds: $1,285,000 (total for all years) Non-Peer Review Title: Cardiovascular Research Source: Robert Wood Johnson Role: Principal Investigator Dates: July 1, 20xx - June 30, 20xx Direct Funds: $50,000 Title: Endocrine Research Source: Merck Pharmaceuticals Role: Principal Investigator Dates: January 1, 20xx - December 30, 20xx Direct Funds: $150,000 B. Pending Peer Review Title: Control of the kidney Source: NIH Role: Principal Investigator Dates: July 1, 20xx - June 30, 20xx Direct Funds: $1,285,000 (total for all years) Title: Training in Cardiovascular Research Source: NIH Role: Co-Investigator Dates: July 1, 20xx - June 30, 20xx Direct Funds: $1,285,000 (total for all years) Non-Peer Review Title: Cardiovascular Research Source: Robert Wood Johnson Role: Co-Investigator Dates: July 1, 20xx - June 30, 20xx Direct Funds: $50,000 C. Prior Peer Review Title: Training in Cardiovascular Research Source: NIH Role: Principal Investigator Dates: July 1, 20xx - June 30, 20xx Direct Funds: $1,285,000 (total for all years) Non-Peer Review Title: Cardiovascular Research Source: Robert Wood Johnson Role: Principal Investigator Dates: July 1, 20xx - June 30, 20xx Direct Funds: $50,000 21. INVITED LECTURES/WORKSHOPS/PRESENTATIONS (must be invited to participate): International Author(s), Title, Meeting/Event, Location and Date (mm/yyyy - mm/yyyy) (Jane Doe, Lecture about my research, Visiting Professor, University of London, 5/5/05) National Author(s), Title, Meeting/Event, Location and Date (mm/yyyy - mm/yyyy) (John Doe, New ECG techniques workshop, American Heart Meeting, Dallas, 5/5/05- 5/9/05) (Jane Doe, Distinguished Lectureship, American Physiological Society, Washington, D.C. 5/5/05-5/9/05) Regional Author(s), Title, Meeting/Event, Location and Date (mm/yyyy - mm/yyyy) Local Author(s), Title, Meeting/Event, Location and Date (mm/yyyy - mm/yyyy) 22. PEER REVIEWED WORKSHOPS/PRESENTATIONS (must have abstract or submission peer reviewed before asked to present): International Author(s), Title, Meeting/Event, Location and Date (mm/yyyy - mm/yyyy) National Author(s), Title, Meeting/Event, Location and Date (mm/yyyy - mm/yyyy) (John Doe, My new data, American Heart Meeting, Dallas, 5/5/05 – 5/9/05) Regional Author(s), Title, Meeting/Event, Location and Date (mm/yyyy - mm/yyyy) Local Author(s), Title, Meeting/Event, Location and Date (mm/yyyy - mm/yyyy) 23. COMMITTEE SERVICE: Medical College Committees mm/yyyy - mm/yyyy - Member, Committee on Rank & Tenure, Medical College of Wisconsin mm/yyyy - mm/yyyy - Department of Medicine Committee on Faculty Development Hospital Committees mm/yyyy - mm/yyyy - Member, Credential Committee, Froedtert Memorial Hospital mm/yyyy - mm/yyyy - Member, Billing Committee Children’s Hospital of Wisconsin 24. MEDICAL COLLEGE TEACHING ACTIVITIES: Medical Student Education mm/yyyy - mm/yyyy Activity Information Graduate Student Education mm/yyyy - mm/yyyy Activity Information Resident & Fellow Education mm/yyyy - mm/yyyy Activity Information Postdoctoral Fellow Education mm/yyyy - mm/yyyy Activity Information Continuing Medical Education mm/yyyy - mm/yyyy Activity Information Community/Lay Public mm/yyyy - mm/yyyy Activity Information 25. EXTRAMURAL TEACHING (e.g. at Marquette, UWM, etc.): 26. MCW STUDENTS, FACULTY. RESIDENTS AND CLINICAL/RESEARCH FELLOWS MENTORED: Medical Students Student mm/yyyy - mm/yyyy Capacity (e.g. summer student mentor, research mentor, etc.). Graduate Students Ph.D. Students Advised Student mm/yyyy - mm/yyyy Dissertation title M.S. Students Advised Student mm/yyyy - mm/yyyy Thesis title Ph.D./M.S. Committees Student mm/yyyy - mm/yyyy Student (degree) Clinical/Research Fellows Fellow mm/yyyy - mm/yyyy Capacity (Advisor, research mentor, sponsor KO8). Residents Resident mm/yyyy - mm/yyyy Capacity (Research, teaching, clinical mentor) Faculty Facultymm/yyyy - mm/yyyy Capacity (Research, teaching, clinical mentor) 27. EXTRAMURAL STUDENTS. FACULTY, RESIDENTS, AND CLINICAL/RESEARCH FELLOWS MENTORED: 28. PROGRAMMATIC DEVELOPMENTS Educational Programs Student Resident Fellow Faculty Research Programs Clinical Programs Community Programs 29. COMMUNITY SERVICE ACTIVITIES: BIBLIOGRAPHY REFEREED JOURNAL PUBLICATIONS/ORIGINAL PAPERS 1. DOE, J., Jeffrey, A., Daley, J., Robbins, K., Journal of Clinical Investigation. Medical Service Publishing Company, 19xx - 19xx. 2. DOE, J., Smith, K., Cohen, J.,: Characterization of normal and abnormal pulmonary surface by reflected ultrasound. J Amer Soc Echo 3:140-145, 20xx BOOKS, CHAPTERS & REVIEWS Jones, J., DOE, J., Wann, JC., : Stress Doppler echocardiography. Cardio 6:45, 19xx. EDITORIALS, LETTERS TO EDITOR, OTHER 1. DOE, J. and Cohen J: Body weight changes effect on heart. New Eng. J. Med. 541:22-40, 20xx. NON-REFEREED JOURNAL PUBLICATIONS/ORIGINAL PAPERS ABSTRACTS 1. Jeffrey, A., DOE, J. : Low cardiac output. Clinic Res. p. 108-109, 20xx. PEER REVIEWED EDUCATIONAL PRODUCTS (Video, Syllabi, or Other Teaching/Educational Materials) NON-PEER REVIEWED EDUCATIONAL PRODUCTS (Video, Syllabi, or Other Teaching/Educational Materials) DATABASE, VIDEO, OR OTHER RESEARCH/CLINICAL CONTRIBUTIONS SOFTWARE, SOFTWARE MODULES .