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pdfOMB No. 0925-0001
Form Approved Through 09/30/2007
LEAVE BLANK—FOR PHS USE ONLY.
Type
Activity
Number
Review Group
Formerly
Department of Health and Human Services
Public Health Services
Grant Application
Council/Board (Month, Year)
Do not exceed character length restrictions indicated.
1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation.)
Date Received
2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION
(If “Yes,” state number and title)
Title:
Number:
No
NO
3. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR
New Investigator
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3c. POSITION TITLE
3d. MAILING ADDRESS (Street, city, state, zip code)
YES
Yes
3h. eRA Commons User Name
3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3f. MAJOR SUBDIVISION
3g. TELEPHONE AND FAX (Area code, number and extension)
TEL:
E-MAIL ADDRESS:
FAX:
4. HUMAN SUBJECTS 4b. Human Subjects Assurance No.
RESEARCH
No
Yes
4c. Clinical Trial
No
Yes
5. VERTEBRATE ANIMALS
4d. NIH-defined Phase III
Clinical Trial
No
Yes
5a. If “Yes,” IACUC approval
Date
No
Yes
5b. Animal welfare assurance no.
4a. Research Exempt
If “Yes,” Exemption No.
No
Yes
6. DATES OF PROPOSED PERIOD OF
SUPPORT (month, day, year—MM/DD/YY)
7. COSTS REQUESTED FOR INITIAL
BUDGET PERIOD
8. COSTS REQUESTED FOR PROPOSED
PERIOD OF SUPPORT
From
7a. Direct Costs ($)
8a. Direct Costs ($)
Through
7b. Total Costs ($)
9. APPLICANT ORGANIZATION
Name
8b. Total Costs ($)
10. TYPE OF ORGANIZATION
Address
Public:
→
Federal
Private:
→
Private Nonprofit
For-profit: →
Woman-owned
General
State
Local
Small Business
Socially and Economically Disadvantaged
11. ENTITY IDENTIFICATION NUMBER
DUNS NO.
Cong. District
12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE
Name
13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name
Title
Title
Address
Address
Tel:
E-Mail:
FAX:
Tel:
FAX:
E-Mail:
14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that
SIGNATURE OF OFFICIAL NAMED IN 13.
the statements herein are true, complete and accurate to the best of my knowledge, and
(In ink. “Per” signature not acceptable.)
accept the obligation to comply with Public Health Services terms and conditions if a grant
is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent
statements or claims may subject me to criminal, civil, or administrative penalties.
PHS 398 (Rev. 04/06)
Face Page
DATE
Form Page 1
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(This reminder will not appear on the printed form.)
Use only if responding to a Multiple PI pilot initiative. See http://grants.nih.gov/grants/multi_pi/index.htm for details.
Contact Principal Investigator/Program Director (Last, First, Middle):
3. PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3h. NIH Commons User Name
3c. POSITION TITLE
3d. MAILING ADDRESS (Street, city, state, zip code)
3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3f. MAJOR SUBDIVISION
3g. TELEPHONE AND FAX (Area code, number and extension)
TEL:
E-MAIL ADDRESS:
FAX:
3. PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3h. NIH Commons User Name
3c. POSITION TITLE
3d. MAILING ADDRESS (Street, city, state, zip code)
3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3f. MAJOR SUBDIVISION
3g. TELEPHONE AND FAX (Area code, number and extension)
TEL:
E-MAIL ADDRESS:
FAX:
3. PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3h. NIH Commons User Name
3c. POSITION TITLE
3d. MAILING ADDRESS (Street, city, state, zip code)
3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3f. MAJOR SUBDIVISION
3g. TELEPHONE AND FAX (Area code, number and extension)
TEL:
E-MAIL ADDRESS:
FAX:
3. PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3h. NIH Commons User Name
3c. POSITION TITLE
3d. MAILING ADDRESS (Street, city, state, zip code)
3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3f. MAJOR SUBDIVISION
3g. TELEPHONE AND FAX (Area code, number and extension)
TEL:
PHS 398 (Rev. 04/06)
E-MAIL ADDRESS:
FAX:
Face Page-continued
Form Page 1-continued
Principal Investigator/Program Director (Last, First, Middle):
DESCRIPTION: See instructions. State the application’s broad, long-term objectives and specific aims, making reference to the health relatedness of
the project (i.e., relevance to the mission of the agency). Describe concisely the research design and methods for achieving these goals. Describe
the rationale and techniques you will use to pursue these goals.
In addition, in two or three sentences, describe in plain, lay language the relevance of this research to public health. If the application is funded, this
description, as is, will become public information. Therefore, do not include proprietary/confidential information. DO NOT EXCEED THE SPACE
PROVIDED.
PERFORMANCE SITE(S) (organization, city, state)
PHS 398 (Rev. 04/06)
Page 2
Form Page 2
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Principal Investigator/Program Director (Last, First, Middle):
KEY PERSONNEL. See instructions. Use continuation pages as needed to provide the required information in the format shown below.
Start with Principal Investigator(s). List all other key personnel in alphabetical order, last name first.
Name
eRA Commons User Name
OTHER SIGNIFICANT CONTRIBUTORS
Name
Organization
Organization
Role on Project
Role on Project
Human Embryonic Stem Cells
No
Yes
If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list:
http://stemcells.nih.gov/registry/index.asp. Use continuation pages as needed.
If a specific line cannot be referenced at this time, include a statement that one from the Registry will be used.
Cell Line
PHS 398 (Rev. 04/06)
Page 3
Form Page 2-continued
Number the following pages consecutively throughout
the application. Do not use suffixes such as 4a, 4b.
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(This reminder will not appear on the printed form.)
Principal Investigator/Program Director (Last, First, Middle):
The name of the principal investigator/program director must be provided at the top of each printed page and each continuation page.
RESEARCH GRANT
TABLE OF CONTENTS
Page Numbers
Face Page..................................................................................................................................................
Description, Performance Sites, Key Personnel, Other Significant Contributors, and Human
Embryonic Stem Cells .............................................................................................................................
Table of Contents .....................................................................................................................................
1
2
Detailed Budget for Initial Budget Period (or Modular Budget) ..........................................................
Budget for Entire Proposed Period of Support (not applicable with Modular Budget) .............................
Budgets Pertaining to Consortium/Contractual Arrangements (not applicable with Modular Budget)
Biographical Sketch – Principal Investigator/Program Director (Not to exceed four pages)..................
Other Biographical Sketches (Not to exceed four pages for each – See instructions) .........................
Resources .................................................................................................................................................
Research Plan...........................................................................................................................................
Introduction to Revised/Resubmission Application (Not to exceed 3 pages.) . .................................................................................
Introduction to Supplemental/Revision Application (Not to exceed one page.) .................................................................................
A. Specific Aims ..........................................................................................................................................................................
B. Background and Significance .................................................................................................................................................
C. Preliminary Studies/Progress Report
(Items A-D: not to exceed 25 pages)........................
D. Research Design and Methods...............................................................................................................................................
E. Human Subjects Research .....................................................................................................................................................
Protection of Human Subjects (Required if Item 4 on the Face Page is marked “Yes”) .....................................................
Data and Safety Monitoring Plan (Required if Item 4 on the Face Page is marked “Yes” and a Phase I, II,
or III clinical trial is proposed) ......................................................................................................................................
Inclusion of Women and Minorities (Required if Item 4 on the Face Page is marked “Yes” and is Clinical Research) .....
Targeted/Planned Enrollment Table (for new and continuing clinical research studies) .............................................
Inclusion of Children (Required if Item 4 on the Face Page is marked “Yes”) ...................................................................
F. Vertebrate Animals .................................................................................................................................................................
G. Select Agent Research ...........................................................................................................................................................
H. Literature Cited .......................................................................................................................................................................
I.
Multiple PI Leadership Plan ....................................................................................................................................................
J. Consortium/Contractual Arrangements...................................................................................................................................
K. Resource Sharing ...................................................................................................................................................................
L. Letters of Support (e.g., Consultants) .....................................................................................................................................
Checklist....................................................................................................................................................
Appendix
(Five collated sets. No page numbering necessary for Appendix.)
Check if
Appendix is
Included
Number of publications and manuscripts accepted for publication (not to exceed 10)
Other items (list):
PHS 398 (Rev. 04/06)
Page
Form Page 3
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Principal Investigator/Program Director (Last, First, Middle):
DETAILED BUDGET FOR INITIAL BUDGET PERIOD
DIRECT COSTS ONLY
PERSONNEL (Applicant organization only)
ROLE ON
PROJECT
NAME
DOLLAR AMOUNT REQUESTED (omit cents)
Months Devoted to Project
Cal.
Mnths
Acad.
Mnths
THROUGH
FROM
Summer INST.BASE
SALARY
Mnths
SALARY
REQUESTED
FRINGE
BENEFITS
TOTAL
Principal
Investigator
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTS
INPATIENT
OUTPATIENT
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
CONSORTIUM/CONTRACTUAL COSTS
DIRECT COSTS
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)
FACILITIES AND ADMINISTRATIVE COSTS
CONSORTIUM/CONTRACTUAL COSTS
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD
PHS 398 (Rev. 04/06)
$
Page
$
Form Page 4
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Principal Investigator/Program Director (Last, First, Middle):
BUDGET FOR ENTIRE PROPOSED PROJECT PERIOD
DIRECT COSTS ONLY
BUDGET CATEGORY
TOTALS
INITIAL BUDGET
PERIOD
(from Form Page 4)
ADDITIONAL YEARS OF SUPPORT REQUESTED
2nd
3rd
4th
5th
PERSONNEL: Salary and fringe
benefits. Applicant organization
only.
CONSULTANT COSTS
EQUIPMENT
SUPPLIES
TRAVEL
PATIENT
CARE
COSTS
INPATIENT
OUTPATIENT
ALTERATIONS AND
RENOVATIONS
OTHER EXPENSES
CONSORTIUM/
CONTRACTUAL
COSTS
DIRECT
SUBTOTAL DIRECT COSTS
(Sum = Item 8a, Face Page)
CONSORTIUM/
CONTRACTUAL
COSTS
F&A
TOTAL DIRECT COSTS
TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD
$
JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.
PHS 398 (Rev. 04/06)
Page
Form Page 5
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Principal Investigator/Program Director (Last, First, Middle):
BUDGET JUSTIFICATION PAGE
MODULAR RESEARCH GRANT APPLICATION
Initial Period
2nd
3rd
4th
5 th
Sum Total
(For Entire Project
Period)
DC less Consortium F&A
(Item 7a, Face Page)
(Item 8a, Face Page)
Consortium F&A
$
Total Direct Costs
Personnel
Consortium
PHS 398 (Rev. 04/06)
Page
Modular Budget Format Page
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Principal Investigator/Program Director (Last, first, middle):
RESOURCES
FACILITIES: Specify the facilities to be used for the conduct of the proposed research. Indicate the performance sites and describe capacities,
pertinent capabilities, relative proximity, and extent of availability to the project. If research involving Select Agent(s) will occur at any performance
site(s), the biocontainment resources available at each site should be described. Under “Other,” identify support services such as machine shop,
electronics shop, and specify the extent to which they will be available to the project. Use continuation pages if necessary.
Laboratory:
Clinical:
Animal:
Computer:
Office:
Other:
MAJOR EQUIPMENT: List the most important equipment items already available for this project, noting the location and pertinent capabilities of each.
PHS 398 (Rev. 04/06)
Page
Resources Format Page
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Principal Investigator/Program Director (last, First, Middle):
CHECKLIST
TYPE OF APPLICATION (Check all that apply.)
NEW application. (This application is being submitted to the PHS for the first time.)
REVISION/RESUBMISSION of application number:
(This application replaces a prior unfunded version of a new, competing continuation/renewal, or supplemental/revision application.)
INVENTIONS AND PATENTS
(Competing continuation/renewal appl. only)
COMPETING CONTINUATION/RENEWAL of grant number:
(This application is to extend a funded grant beyond its current project period.)
No
SUPPLEMENT/REVISION to grant number:
Previously reported
Yes. If “Yes,”
(This application is for additional funds to supplement a currently funded grant.)
Not previously reported
CHANGE of principal investigator/program director.
Name of former principal investigator/program director:
CHANGE of Grantee Institution.
FOREIGN application
Name of former institution:
Domestic Grant with foreign involvement
List Country(ies)
Involved:
1. PROGRAM INCOME (See instructions.)
All applications must indicate whether program income is anticipated during the period(s) for which grant support is request. If program income is
anticipated, use the format below to reflect the amount and source(s).
Budget Period
Anticipated Amount
Source(s)
2. ASSURANCES/CERTIFICATIONS (See instructions.)
In signing the application Face Page, the authorized organizational
representative agrees to comply with the following policies, assurances
and/or certifications when applicable. Descriptions of individual
assurances/certifications are provided in Part III. If unable to certify
compliance, where applicable, provide an explanation and place it after
this page.
•Human Subjects Research •Research Using Human Embryonic Stem
Cells •Research on Transplantation of Human Fetal Tissue •Women and
Minority Inclusion Policy •Inclusion of Children Policy •Vertebrate Animals•
•Debarment and Suspension •Drug-Free Workplace (applicable to new
[Type 1] or revised/resubmission [Type 1] applications only) •Lobbying
•Non-Delinquency on Federal Debt •Research Misconduct •Civil Rights
(Form HHS 441 or HHS 690) •Handicapped Individuals (Form HHS 641
or HHS 690) •Sex Discrimination (Form HHS 639-A or HHS 690) •Age
Discrimination (Form HHS 680 or HHS 690) •Recombinant DNA
Research, Including Human Gene Transfer Research •Financial Conflict
of Interest •Smoke Free Workplace •Prohibited Research •Select Agent
Research •PI Assurance
3. FACILITIES AND ADMINSTRATIVE COSTS (F&A)/ INDIRECT COSTS. See specific instructions.
DHHS Agreement dated:
No Facilities And Administrative Costs Requested.
DHHS Agreement being negotiated with
Regional Office.
No DHHS Agreement, but rate established with
Date
CALCULATION* (The entire grant application, including the Checklist, will be reproduced and provided to peer reviewers as confidential information.)
0.00% % = F&A costs
0.00% % = F&A costs
a. Initial budget period:
Amount of base $
x Rate applied
$
b. 02 year
Amount of base $
x Rate applied
c. 03 year
Amount of base $
x Rate applied
d. 04 year
Amount of base $
x Rate applied
0.00% % = F&A costs
0.00% % = F&A costs
e. 05 year
Amount of base $
x Rate applied
0.00% % = F&A costs
$
Enter Rate above as a decimal (e.g., 0.25 for 25%, 0.495 for 49.5%) TOTAL F&A Costs
$
$
$
$
*Check appropriate box(es):
Salary and wages base
Modified total direct cost base
Other base (Explain)
Off-site, other special rate, or more than one rate involved (Explain)
Explanation (Attach separate sheet, if necessary.):
PHS 398 (Rev. 04/06)
Page
Checklist Form Page
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Principal Investigator/Program Director (Last, First, Middle):
Place this form at the end of the signed original copy of the application.
Do not duplicate.
PERSONAL DATA ON
PRINCIPAL INVESTIGATOR(S)/PROGRAM DIRECTOR(S)
The Public Health Service has a continuing commitment to monitor the operation of its review and
award processes to detect—and deal appropriately with—any instances of real or apparent inequities
with respect to age, sex, race, or ethnicity of the proposed principal investigator(s)/program director(s).
To provide the PHS with the information it needs for this important task, complete the form below and
attach it to the signed original of the application after the Checklist. When multiple PIs/PDs are
proposed, complete a form for each. Do not attach copies of this form to the duplicated copies of
the application.
Upon receipt of the application by the PHS, this form will be separated from the application. This form
will not be duplicated, and it will not be a part of the review process. Data will be confidential, and will
be maintained in Privacy Act record system 09-25-0036, “Grants: IMPAC (Grant/Contract Information).”
The PHS requests the last four digits of the Social Security Number for accurate identification, referral,
and review of applications and for management of PHS grant programs. Although the provision of this
portion of the Social Security Number is voluntary, providing this information may improve both the
accuracy and speed of processing the application. Please be aware that no individual will be denied
any right, benefit, or privilege provided by law because of refusal to disclose this section of the Social
Security Number. The PHS requests the last four digits of the Social Security Number under Sections
301(a) and 487 of the PHS Acts as amended (42 U.S.C 241a and U.S.C. 288). All analyses conducted
on the date of birth, gender, race and/or ethnic origin data will report aggregate statistical findings only
and will not identify individuals. If you decline to provide this information, it will in no way affect
consideration of your application. Your cooperation will be appreciated.
DATE OF BIRTH (MM/DD/YY)
SOCIAL SECURITY NUMBER
(last 4 digits only)
SEX/GENDER
XXX-XX-
Female
Male
ETHNICITY
1. Do you consider yourself to be Hispanic or Latino? (See definition below.) Select one.
Hispanic or Latino. A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture
or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.”
Hispanic or Latino
Not Hispanic or Latino
RACE
2. What race do you consider yourself to be? Select one or more of the following.
American Indian or Alaska Native. A person having origins in any of the original peoples of North, Central, or South
America, and who maintains tribal affiliation or community attachment.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam. (Note: Individuals from the Philippine Islands have been recorded as Pacific Islanders
in previous data collection strategies.)
Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as
“Haitian” or “Negro” can be used in addition to “Black” or African American.”
Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Check here if you do not wish to provide some or all of the above information.
PHS 398 (Rev. 04/06)
DO NOT PAGE NUMBER THIS FORM
Personal Data Form Page
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Principal Investigator/Program Director (Last, First, Middle):
Targeted/Planned Enrollment Table
This report format should NOT be used for data collection from study participants.
Study Title:
Total Planned Enrollment:
TARGETED/PLANNED ENROLLMENT: Number of Subjects
Ethnic Category
Females
Sex/Gender
Males
Total
Hispanic or Latino
Not Hispanic or Latino
Ethnic Category: Total of All Subjects *
Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Racial Categories: Total of All Subjects *
* The “Ethnic Category: Total of All Subjects” must be equal to the “Racial Categories: Total of All Subjects.”
PHS 398/2590 (Rev. 09/04, Reissued 4/2006)
Page
Targeted/Planned Enrollment Format Page
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Principal Investigator/Program Director (Last, First, Middle):
Inclusion Enrollment Report
This report format should NOT be used for data collection from study participants.
Study Title:
Total Enrollment:
Protocol Number:
Grant Number:
PART A. TOTAL ENROLLMENT REPORT: Number of Subjects Enrolled to Date (Cumulative)
by Ethnicity and Race
Sex/Gender
Unknown or
Ethnic Category
Females
Males
Not Reported
Total
**
Hispanic or Latino
Not Hispanic or Latino
Unknown (individuals not reporting ethnicity)
*
Ethnic Category: Total of All Subjects*
Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Unknown or Not Reported
*
Racial Categories: Total of All Subjects*
PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics or Latinos Enrolled to Date (Cumulative)
Racial Categories
Females
Males
Unknown or
Not Reported
Total
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Unknown or Not Reported
**
Racial Categories: Total of Hispanics or Latinos**
* These totals must agree.
** These totals must agree.
PHS 398/2590 (Rev. 09/04, Reissued 4/2006)
Page
In
nclusion Enrollment Report Format Page
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CDA TOC Substitute Page
Candidate (Last, first, middle):
Use this substitute page for the Table of Contents of Research Career Development Awards. Type the name of the candidate at the
top of each printed page and each continuation page.
RESEARCH CAREER DEVELOPMENT AWARD
TABLE OF CONTENTS (Substitute Page)
Page Numbers
Letters of Reference* (attach unopened references to the Face Page)
Section I: Basic Administrative Data
Face Page (Form Page 1) .................................................................................................................................................................
Description, Performance Sites, Key Personnel, Other Significant Contributors, and Human Embryonic Stem Cells (Form Page 2)
1
2
Table of Contents (this CDA Substitute Form Page 3) ………………………………………………………………………………………
Budget for Entire Proposed Period of Support (Form Page 5) ..........................................................................................................
Biographical Sketches (Candidate, Sponsor[s],* Key Personnel and Other Significant Contributors*
—Biographical Sketch Format page) (Not to exceed four pages) .................................................................................................
Other Support Pages (not for the candidate) .....................................................................................................................................
Resources (Resources Format page) ................................................................................................................................................
Section II: Specialized Information
Introduction to Revised/Resubmission Application* (Not to exceed 3 pages) ............................................................................
1. The Candidate
A. Candidate’s Background ..........................................................................................................................................................
B. Career Goals and Objectives: Scientific Biography .............................……… (Items A-D included in 25 page limit) .............
C. Career Development/Training Activities during Award Period ................................................................................................
D. Training in the Responsible Conduct of Research …………………………………………………………………………………..
2. Statements by Sponsor, Co-Sponsor(s),* Consultant(s),* and Contributor(s)* .....................................................................
3. Environment and Institutional Commitment to Candidate
A. Description of Institutional Environment ..................................................................................................................................
B. Institutional Commitment to Candidate’s Research Career Development. ..............................................................................
4. Research Plan
A. Specific Aims ...........................................................................................................................................................................
B. Background and Significance ……………………………………………………. (Items A-D included in 25 page limit) ............
C. Preliminary Studies/Progress Report ......................................................................................................................................
D. Research Design and Methods ...............................................................................................................................................
E. Human Subjects Research ......................................................................................................................................................
Targeted/Planned Enrollment Table (for new and continuing clinical research studies) .......................................................
F. Vertebrate Animals ..................................................................................................................................................................
G. Select Agent Research.............................................................................................................................................................
H. Literature Cited. ........................................................................................................................................................................
I. Consortium/Contractual Arrangements* ...................................................................................................................................
J. Resource Sharing.....................................................................................................................................................................
Checklist ………………………………………………………………….................................................................................................
Appendix (Five collated sets. No page numbering necessary.)
Check if Appendix is included
Number of publications and manuscripts accepted for publication (not to exceed 5)
List of Key Items:
Note: Font and margin requirements must conform to limits provided in the Specific Instructions.
*Include these items only when applicable.
CITIZENSHIP
U.S. citizen or
non-citizen national
PHS 398 (Rev. 04/06)
Permanent resident of U.S. (If a permanent resident of the U.S., a
notarized statement must be provided by the time of award.)
Page
Non-citizen with temporary visa
(Applicable for only the K99 program)
CDA Substitute Form Page 3
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CAREER DEVELOPMENT AWARD REFERENCE REPORT GUIDELINES
(Series K)
Title of Award:
Type of Award:
Application Submission Deadline:
Name of Candidate (Last, first, middle):
Name of Respondent (Last, first, middle):
The candidate is applying to the National Institutes of Health for a Career Development Award (CDA). The purpose
of this award is to develop the research capabilities and career of the applicant. These awards provide up to five
years of salary support and guarantee them the ability to devote at least 75–80 percent of their time to research for the
duration of the award. Many of these awards also provide funds for research and career development costs. The
award is available to persons who have demonstrated considerable potential to become independent researchers,
but who need additional supervised research experience in a productive scientific setting.
We would appreciate receiving your evaluation of the above candidate with special reference to:
• potential for conducting research;
• evidence of originality;
• adequacy of scientific background;
• quality of research endeavors or publications to date, if any;
• commitment to health-oriented research; and
• need for further research experience and training.
Any related comments that you may wish to provide would be welcomed. These references will be used by PHS
committees of consultants in assessing candidates.
Complete the report in English on 8-1/2 x 11" sheets of paper. Return your reference report to the candidate
sealed in the envelope as soon as possible and in sufficient time so that the candidate can meet the application
submission deadline. References must be submitted with the application.
We have asked the candidate to provide you with a self-addressed envelope with the following words in the front
bottom corner: “DO NOT OPEN—PHS USE ONLY.” Candidates are not to open the references. Under the Privacy Act
of 1974, CDA candidates may request personal information contained in their records, including this reference. Thank
you for your assistance.
PHS 398 (Rev. 09/04, Reissued 4/2006)
SAMPLE
CDA Reference Guidelines Format Page
Print all forms actual size to meet formatting specifications. Make sure "Shrink oversized pages to paper size" is NOT checked on Print window.
(This reminder will not appear on the printed form.)
Kirschstein-NRSA TOC
Substitute Page
Principal Investigator/Program Director
(Last, first, middle):
Type the name of the principal investigator/program director at the top of each printed page and each continuation page. (For type specifications, see
PHS 398 Instructions.)
INSTITUTIONAL RUTH L. KIRSCHSTEIN NATIONAL RESEARCH SERVICE AWARD
TABLE OF CONTENTS (Substitute Page)
Page Numbers
Face Page (Form Page 1) ………………………………………………………………………………………
1
Description, Performance Sites, Key Personnel, Other Significant Contributors, and Human
Embryonic Stem Cells (Form Page 2, Form Page 2-continued, and additional continuation page,
if necessary) ………….…………………………………………………………………………………………..
2
Table of Contents (this Kirschstein-NRSA Substitute Form Page 3) ………………………………….
Detailed Budget for Initial Budget Period (Kirschstein-NRSA Substitute Form Page 4) .................
Budget for Entire Proposed Period of Support (Kirschstein-NRSA Substitute Form Page 5) ........
Biographical Sketch—Principal Investigator/Program Director (Not to exceed four pages) .........
Other Biographical Sketches (Not to exceed four pages for each) ..................................................
Resources ................................................................................................................................................
Research Training Program Plan
Introduction to Revised/Resubmission Application, if applicable (Not to exceed 3 pages)........................................
Introduction to Supplemental/Revision Application, if applicable (Not to exceed one page) ....................................
A. Background .............................................................................................................................................................................
B. Program Plan ..........................................................................................................................................................................
1. Program Administration ..................................................................................................................................................
2. Program Faculty ...........................…………………………………………………(Items A-D: not to exceed 25 pages, ....
3. Proposed Training .....................................………………………………………..excluding tables*) .................................
4. Training Program Evaluation …………………………………………………………………………………………………….
5. Trainee Candidates .........................................................................................................................................................
C. Minority Recruitment and Retention Plan . ..............................................................................................................................
D. Plan for Instruction in the Responsible Conduct of Research ................................................................................................
E. Progress Report (Competing Continuation Applications Only) ...............................................................................................
F. Human Subjects ......................................................................................................................................................................
G. Vertebrate Animals .................................................................................................................................................................
H. Select Agent Research............................................................................................................................................................
I. Multiple PI Leadership Plan (if applicable) ...............................................................................................................................
J. Consortium/Contractual Arrangements ....................................................................................................................................
Checklist …………………………………………………………………………………………………………..
Appendix
(Five collated sets. No page numbering necessary for Appendix.)
Check if
Appendix is
included
* Font and margin requirements must conform to limits provided in PHS 398 Specific Instructions.
PHS 398 (Rev. 04/06)
Page
Kirschstein-NRSA Substitute Form Page 3
Print all forms actual size to meet formatting specifications. Make sure "Shrink oversized pages to paper size" is NOT checked on Print window.
(This reminder will not appear on the printed form.)
Kirschstein-NRSA Initial Budget
Period Substitute Page
Principal Investigator/Program Director:
(Last, first, middle)
DETAILED BUDGET FOR INITIAL BUDGET PERIOD
DIRECT COSTS ONLY (Kirschstein-NRSA Substitute Page)
FROM
THROUGH
STIPENDS
DOLLAR TOTAL
PREDOCTORAL
No. Requested:
POSTDOCTORAL (Itemize)
No. Requested:
OTHER (Specify)
No. Requested:
TOTAL STIPENDS
TUITION and FEES (Itemize)
TRAINEE TRAVEL (Describe)
TRAINEE RELATED EXPENSES (including Health Insurance)
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Also enter on Face Page, Item 7)
PHS 398 (Rev. 09/04, Reissued 4/2006)
Page
$
Kirschstein-NRSA Substitute Form Page 4
Print all forms actual size to meet formatting specifications. Make sure "Shrink oversized pages to paper size" is NOT checked on Print window.
(This reminder will not appear on the printed form.)
Kirschstein-NRSA Entire Budget
Period Substitute Page
Principal Investigator/Program Director:
(Last, first, middle)
BUDGET FOR ENTIRE PROPOSED PERIOD OF SUPPORT
DIRECT COSTS ONLY (Kirschstein-NRSA Substitute Page)
BUDGET CATEGORY
INITIAL BUDGET
PERIOD
TOTALS
(from Form Page 4)
No.
ADDITIONAL YEARS OF SUPPORT REQUESTED
2nd
No.
3rd
No.
4th
5th
No.
No.
PREDOCTORAL STIPENDS
POSTDOCTORAL STIPENDS
OTHER STIPENDS
TOTAL STIPENDS
TUITION AND FEES
TRAINEE TRAVEL
TRAINEE RELATED
EXPENSES (including Health
Insurance)
TOTAL DIRECT COSTS
TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD (Item 8a, Face Page)
$
JUSTIFICATION. For all years, explain the basis for the budget categories requested. Follow the instructions for the Initial Budget
Period and include anticipated postdoctoral levels.
PHS 398 (Rev. 09/04, Reissued 4/2006)
Page
Kirschstein-NRSA Substitute Form Page 5
Print all forms actual size to meet formatting specifications. Make sure "Shrink oversized pages to paper size" is NOT checked on Print window.
(This reminder will not appear on the printed form.)
Principal Investigator/Program Director (Last, First, Middle):
DO NOT SUBMIT UNLESS REQUESTED
Competing Continuation Applications
KEY PERSONNEL REPORT
All Key Personnel for the Current Budget Period
Name
PHS 398 (Rev. 04/06)
Degree(s)
SSN
(last 4
digits)
Page
Months Devoted to Project
Role on Project
(e.g. PI, Res. Assoc.)
Date of Birth
(MM/DD/YY)
Cal
Acad
Summer
Key Personnel Report Format Page
Print all forms actual size to meet formatting specifications. Make sure "Shrink oversized pages to paper size" is NOT checked on Print window.
(This reminder will not appear on the printed form.)
Mailing address for application
Use this label or a facsimile
All applications and other deliveries to the Center for Scientific Review must come either via
courier delivery or via the United States Postal Service (USPS.) Applications delivered by
individuals to the Center for Scientific Review will no longer be accepted.
Applications sent via the USPS EXPRESS or REGULAR MAIL should be sent to the following address:
CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE
ROOM 1040 – MSC 7710
BETHESDA, MD 20892-7710
NOTE: All applications sent via a courier delivery service (non-USPS) should use this address, but
CHANGE THE ZIP CODE TO 20817
The telephone number is 301-435-0715. C.O.D. applications will not be accepted.
For application in response to RFA
Use this label or a facsimile
IF THIS APPLICATION IS IN RESPONSE TO AN RFA, be sure to put the RFA number in line 2 of the application face
page. In addition, after duplicating copies of the application, cut along the dotted line below and staple the RFA label to
the bottom of the face page of the original and place the original on top of your entire package. Failure to use this RFA
label could result in delayed processing of your application such that it may not reach the review committee on time for
review. Do not use the label unless the application is in response to a specific RFA. Also, applicants responding to a
specific RFA should be sure to follow all special mailing instructions published in the RFA.
RFA No. ___________________
Mailing address for application
Use this label or a facsimile
All applications and other deliveries to the Center for Scientific Review must come either via
courier delivery or via the USPS. Applications delivered by individuals to the Center for
Scientific Review will no longer be accepted.
Applications sent via the USPS EXPRESS or REGULAR MAIL should be sent to the following address:
CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE
ROOM 1040 – MSC 7710
BETHESDA, MD 20892-7710
NOTE: All applications sent via a courier delivery service (non-USPS) should use this address, but
CHANGE THE ZIP CODE TO 20817
The telephone number is 301-435-0715. C.O.D. applications will not be accepted.
For application in response to SBIR/STTR
Use this label or a facsimile
IF THIS APPLICATION IS IN RESPONSE TO AN SBIR/STTR Solicitation, be sure to put the SBIR/STTR Solicitation
number in line 2 of the application face page. In addition, after duplicating copies of the application, cut along the dotted
line below and staple the appropriate SBIR or STTR label to the bottom of the face page of the original and place the
original on top of your entire package. If this SBIR or STTR application is in response to an RFA, be sure to also include
the RFA No. in the space provided below.
SBIR
RFA No. ___________________(if applicable)
STTR
RFA No. ___________________(if applicable)
| File Type | application/pdf |
| File Title | PHS 398 (Rev. 4/06), combined forms file |
| Subject | PHS Grant Application, PHS 398 (Rev. 4/06), combined forms file |
| Author | Office of Extramural Programs |
| File Modified | 2006-11-15 |
| File Created | 2004-02-18 |