Form Approved Through 10/31/2011 OMB No. 0925-0002 |
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Department of Health and Human Services Public Health Service |
Review Group
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Type
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Activity
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Fellowship Number
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Ruth L. Kirschstein
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Total Project Period |
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From: |
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Through: |
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Requested Budget Period |
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From: |
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Through: |
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1. TITLE OF RESEARCH TRAINING PROPOSAL
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2a. FELLOW (Name and address, street, city, state, zip code)
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2b. FELLOW’S E-MAIL ADDRESS
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2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
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2d. MAJOR SUBDIVISION
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3a. NAME OF SPONSOR
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3b. SPONSOR’S E-MAIL ADDRESS
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4. SPONSORING INSTITUTION (Name and address, street, city, state, zip code)
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6a. TITLE AND ADDRESS OF OFFICIAL IN SPONSORING INSTITUTION BUSINESS OFFICE
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5. ENTITY IDENTIFICATION NO. |
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6b. E-MAIL ADDRESS: |
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7. HUMAN SUBJECTS NO YES |
9. TRAINING SITE(S) (Organizations and addresses) |
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7a. Research Exempt NO YES |
If Exempt ("Yes" in 7a): Exemption No.
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Organizational Name: |
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If Not Exempt ("No" in 7a): IRB approval date
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DUNS: |
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7b. Federalwide Assurance No. |
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Street 1: |
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7c. NIH Defined Phase III Clinical Trial |
NO YES |
Street 2: |
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8. VERTEBRATE ANIMALS NO YES |
City: |
County: |
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8a.
If “Yes,”
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8b. Animal welfare assurance no.
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State: |
Province: |
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Country: |
Zip/Postal Code: |
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10. NAME AND TITLE OF OFFICIAL SIGNING FOR APPLICANT ORGANIZATION (Item 13) |
Congressional Districts: |
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NAME |
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11. FELLOW’S TELEPHONE INFORMATION |
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TITLE |
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OFFICE |
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TEL |
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FAX |
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FAX |
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HOME |
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12. CORRECTIONS (Items 1 - 6)
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13. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete, and accurate to the best of my knowledge, and I agree to comply with the Public Health Service terms and conditions if a grant is awarded as a result of this report. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. |
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SIGNATURE OF OFFICIAL NAMED IN 10. (In ink. “Per” signature not acceptable.) |
DATE
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PHS 416-9 (Rev. 10/08) Form Page 1
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |