Form 1 Survey

ATTACHMENT – 2

Application, Letter of Recommendation, and Evaluation Form

<Web Page>

Graduate Student Training Programs Application

OMB No. 0925-0501

Expiration Date: XXXX XX, XXXX (Expiration Date is Not the Application Deadline.)

The GPP encourages you to review the following information before completing the on-line application:

• Application Directions

• Frequently Asked Questions

• Application Help

• Privacy Statement

• Respondent Burden

To complete your application to the GPP, the following items are needed:

1. Three letters of recommendation from three individuals that can evaluate your strengths as a future PhD: submitted electronically by the references as directed in the email request.

2. Unofficial Copy of Standardized Examination Scores: may be submitted by mail or fax

3. Official Copy of All Transcripts: submitted by university registrar or by the applicant in sealed & signed envelops from the registrar.

YOUR APPLICATION WILL NOT BE CONSIDERED UNLESS ALL REQUIRED APPLICATIONS AND SUPPLEMENTAL MATERIAL ARE RECEIVED BY THE SPECIFICED DEADLINE LISTED IN THE PARTNERSHIP DESCRIPTION.

After completing the on-line application, send items 2 and 3 to the address listed below.

Graduate Partnerships Program

ATTN: APPLICATION MATERIAL

National Institutes of Health

2 Center Drive: Building 2 / Room 2E06

Bethesda, Maryland 20892-0234

Phone: 301-594-9605

Fax: 301-594-9606

Email: [email protected]

Web: http://gpp.nih.gov

Please, No Staples!

<Web Page>

Privacy Policy

Collection of this information is authorized under 42 U.S.C. 203, 241, 2891-1 and 44 U.S.C. 3101. The primary use of this information is to evaluate your qualifications for research training at the National Institutes of Health. Additional disclosures may be made to law enforcement agencies concerning violations of law or regulation. Application for this program is voluntary, however, in order for us to process your application; you must complete the required fields.

<Web Page>

Respondent Burden

Public reporting burden for this collection of information is estimated to average 30 minutes per responses, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974. ATTN: PRA (0925-0501). Do not return the completed form to this address.

PERSONAL INFORMATION
Greeting title	Menu
First name
Middle name
Last name
Date of birth	Month / Date / Year
Are you a USA Citizen?	Menu
If not a USA Citizen, are you a USA Permanent Resident?	Menu
If International Citizen, what is your country of citizenship?
If International Citizen, what visa do you have for admission into the USA?
What is the Expiration Date of your Visa?
AAMC Identification Number
Language native
Language fluencies

CURRENT ADDRESS
Address valid until (mm/dd/yyyy)
Street or PO Box
Street or PO Box
City
State
Zip code
Country
Phone day
Phone evening
Email address
PERMANENT ADDRESS
Contact Name
Street or PO Box
Street or PO Box
City
State
Zip code
Country
Phone day
Phone evening
Email address

PROSPECTIVE GS PROGRAM SELECTION
BR-Neuroscience
BU-Bioinformatics
GWU-Biomedical
GU-Biomedical Sciences
JHU-Cell, Molecular, Developmental Biology
NYU-Structural Biology
UMD-Biophysics
UMD-Hearing & Speech Sciences
UMT-Molecular Basis of Infectious Diseases
UNC-Cell Motility
UP-Immunology
OX-Biomedical Sciences
CAM-Health Sciences
KI-Neuroscience
NCI-Molecular Pathology
NINR-Nursing Research
NIH-MSTP
…any additional programs

CURRENT GS PROGRAM SELECTION
Individual Agreement (IA)
Bulgaria Consortium (Bulgaria)
Hungary Consortium (Hungary)
KAIST Consortium (Korea)
Karolinska Institutet-Neuroscience (Sweden)
National Defense Medical Center (Twain)
Seoul National University-Biological Sciences (Korea)
Shanghai Second Medical University (China)
Tel Aviv University-Women's Health (Israel)
University of Cambridge-Health Sciences (England)
University of Naples Federico II (Italy)
University of Oxford-Biomedical Sciences (England)
University of Valparaiso-Neuroscience (Chile)
…any additional programs

SCIENTIFIC DISCIPLINE INTERESTS
Choice one	Menu
Choice two (optional)	Menu
Choice three (optional)	Menu

EDUCATION FIELDS (REPEAT UP TO 6 TIMES)
University name
Academic major
Academic minor/second major
Start date
Graduation date (actual/anticipated)
Grade Point Average
Grade Point Average Scale
Degree anticipated/awarded	Menu	Menu	Menu	Menu	Menu	Menu

STANDARDIZED EXAMS - GRE
Date of exam
Verbal score
Quantitative score
Analytical score
Analytical written score

STANDARDIZED EXAM - GRE SUBJECT
Date of exam
Subject	Menu
Subject score

STANDARDIZED EXAMS - MCAT
Date of exam
Verbal score
Physical science score
Biological science score
Writing sample score	Menu
Total score

STANDARDIZED EXAMS - TOEFL
Date of exam
Type of exam (paper/computer)	Menu
Listening score
Writing score
Reading score
Essay rating
Total score

NIH INFORMATION FOR DISSERTATION RESEARCH
NIH Sponsor / Mentor for Dissertation Research
NIH Administrative Officer
NIH Institute-Center
NIH Start Date as a PhD Graduate Student
NIH Address (Building / Room)
NIH Phone Number
NIH Training Duration

RECOMMENDATION LETTERS
Under the Privacy Act of 1974, you have the right to access to the information provided in the letters of recommendation unless you have waived such access. Please indicate your decision for each reference. Your choice will not affect your eligibility for admission.
REFERENCE – ONE
Greeting title
First name
Last name
Position title
Employment institution
Daytime phone
Email address
Waive letter access	Menu
REFERENCE – TWO
Greeting title
First name
Last name
Position title
Employment institution
Daytime phone
Email address
Waive letter access	Menu
REFERENCE – THREE
Greeting title
First name
Last name
Position title
Employment institution
Daytime phone
Email address
Waive letter access	Menu

RESUME COMPONENTS
Research experience
Publications
Presentations
Awards/honors
Extracurricular activities
Personal statement/research proposal
Cover Letter
Additional Information

OPTIONAL STATISTICS
Ethnicity	Menu
Race	Menu
Gender	Menu
Marital Status	Menu
Disability	Menu
How did you learn about the GPP?	Menu

TRAVEL INFORMATION – COMPLETED BY APPLICANT

Travel Form
OMB Number: 0925-0501
Expiration Date: XXXXX XX, XXXX (Expiration Date Is Not the Application Deadline.)

• Privacy Statement

• Respondent Burden

Welcome to the NIH Graduate Partnerships Program on-line form for travel reservations. Please take a moment to complete the following fields to the best of your ability. A GPP staff member or Travel Agent will contact you to confirm your transportation and lodging reservations for your interviews.

After depressing the submit button a new webpage indicating successful submission of your travel information will be displayed. Uploading may take a few moments, please be patient. Contact the GPP if you have any questions or concerns.

Graduate Partnerships Program

National Institutes of Health

2 Center Drive: Building 2 / Room 2E06

Bethesda, Maryland 20892-0234

Phone: 301-594-9605

Fax: 301-594-9606

Email: [email protected]

Web: http://gpp.nih.gov

Best regards,

Graduate Partnerships Program

Name on Government ID
Address (Valid for Next 60-Days)
	Street
	City
	State
	Zip-Code
	Country
	Email
	Phone
NIH-University Partnership
Interview Date(s) at NIH
NIH Campus Location?
Lodging Needed? Nights?
Interview Date(s) at University
University Location?
Lodging Needed? Nights?
Gender (To Arrange Lodging Reservations)
Valid & Active NIH Badge? NIH Trainee?
Travel – Point of Origin to NIH		Location, Airport, Departure Date, Time
Travel – NIH to University		Location, Airport, Departure Date, Time
Travel – University to Point of Origin		Location, Airport, Departure Date, Time
Additional Information

LETTER OF RECOMMENDATION – COMPLETED BY REFERENCE

Recommendation Letter
OMB Number: 0925-0501
Expiration Date: XXXXX XX, XXXX (Expiration Date Is Not the Application Deadline.)

Welcome to the NIH Graduate Partnerships Program on-line letter of recommendation submission website. Your letter of recommendation is very important in our selection process. We would particularly appreciate your comments on the student's overall intelligence, analytical ability, research ability, verbal and writing skills, interpersonal skills, motivation, and maturity. Your overall analysis of their potential to excel in graduate school and as a future scientist would be especially helpful.

After depressing the submit button a new webpage indicating successful submission of your recommendation will be displayed. Uploading the evaluation form and recommendation letter may take a few moments, please be patient. Contact the GPP if you have any questions or concerns.

Graduate Partnerships Program
National Institutes of Health
2 Center Drive: Building 2 / Room 2E06
Bethesda, Maryland 20892-0234

Phone: 301-594-9605
Fax: 301-594-9606
Email: [email protected]
Web: http://gpp.nih.gov

Thank you for submitting your evaluation.

Best regards,

Graduate Partnerships Program

APPLICANT’S INFORMATION
First Name
Last Name
Application Number
REFERENCE INFORMATION
Greeting Title
First Name
Last Name
Position Title
Employment Institution
Address
Address
City
State
Zip-code
Country
Daytime Phone Number
Fax Number
Email Address
APPLICANT'S EVALUATION
How long have you known the applicant?
In what capacity have you known the Applicant?
Intelligence	menu
Analytical Ability	menu
Research Ability	menu
Verbal Ability	menu
Writing Ability	menu
Interpersonal Skills	menu
Motivation for Research	menu
Confidence	menu
Initiative	menu
Honesty	menu
Knowledge of Field	menu
Maturity	menu
Overall Potential as a Scientist	menu
Letter of Recommendation

<Email Message>

LETTER TO APPLICANT – ANONYMOUS RESPONSE

Dear <First-Name>,

Thank you very much for taking the time to consider the NIH Graduate Partnerships Program for your Ph.D. education. Although you did not choose to enter our program we are glad you were able to find a graduate school that met your needs. Please keep NIH in mind when it comes time for your postdoctoral research training! We strongly believe we can provide outstanding research training for post-docs as well as graduate students.

We know your time is valuable, but would appreciate just a few minutes of your time to give us feedback on your experiences during the application and interview process, and your assessment of NIH as a potential site for graduate training. Your ideas are very important to us as we strive to make our application and programs as user-friendly and effective as possible. Your responses will be kept confidential and will have no effect on your participation in other NIH training programs.

Question: Is there any way in which we could have made the application, interview and selection processes easier or better for you?

Question: What two or three attributes or possibilities did you find most attractive about the Graduate Partnerships Program(s) to which you applied?

Question: What were the deciding factors in your choice not to do your PhD through the Graduate Partnerships Program?

Question: What PhD program did you choose and what were the most important positive deciding factors for your choice?

All the best to you,

Pat Wagner Ph.D.,

Director of Admissions & Registrar

Graduate Partnerships Program

National Institutes of Health

2 Center Drive: Building 2 / 2E12

Bethesda, Maryland 20892-0234

Phone: 301-594-9605

Fax: 301-594-9606

Email: [email protected]

Web: http://gpp.nih.gov

47