Form 1 form

	Applicant’s Instructions for Submission of References
	This notice explains the submission of references for Ruth L. Kirschstein National Research Service Award Individual Fellowship applicants. Applications will not be reviewed unless at least three (3) references are received with the application. Applicants are responsible for complete applications reaching the PHS on schedule.
	Submission Process
	Forward reference forms to referees with sufficient lead time so that the completed forms will be part of the application package. Fill out upper right corner before forwarding to referee. Referees should be provided with postage-paid return envelopes addressed to you with the following words in the front bottom left corner —DO NOT OPEN—PHS USE ONLY. Attach unopened references to the front of the original application and submit the entire package by the submission deadline.

	Note to Respondent
	The applicant is applying for a competitive Ruth L. Kirschstein National Research Service Award Individual Fellowship from the Public Health Service (PHS) for research training in health-related areas. Your assessment of the applicant’s potential for a research career is requested. The references will be used by PHS committees of consultants in assessing applicants.
	At least three references must be submitted with the application or the application will be returned. Please complete this form and return it to the applicant in sufficient time for the applicant to meet the deadline date.
	Complete the form in English. The form should be typed if possible. If any part of the form is handwritten, use a black pen. The color blue does not reproduce. If the space provided is inadequate, use an 8-1/2 x 11” sheet of paper and put the applicant’s name in the upper right corner.
	Although the Privacy Act of 1974 allows NSRA applicants to have access to personal information contained in their records, we have asked the applicant to provide you with a self-addressed envelope with — DO NOT OPEN—PHS USE ONLY — in the front bottom left corner. Applicants are asked not to open the references in order to protect the confidentiality of the process. Thank you for your assistance.

PHS estimates that it will take 45 minutes to complete this form. This includes time for reviewing the instructions, gathering needed information, and completing the form. 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. If you have comments regarding this burden estimate or any other aspects of the collection of information, including suggestions for reducing this burden, send comments to NIH Project Clearance Office, 6705 Rockledge Drive MSC 7974, Bethesda, MD 20892-7974, Attention: PRA (0925-0002). DO NOT RETURN THE COMPLETED FORM TO THIS ADDRESS.

Form Approved Through 10/31/2011 OMB No. 0925-0002
Department of Health and Human Services Public Health Service Reference Ruth L. Kirschstein National Research Service Award Individual Fellowship				(Applicant completes this block.)
				NAME OF APPLICANT (Last, first, middle initial)      
				PROPOSED SPONSORING INSTITUTION      
Compare the applicant with other individuals of similar training and experience with whom you have been associated. Use the following numerical scores, from 1 (best) to 5 (poorest). Mark every block; insert “X” if insufficient knowledge to rate and “NA” if not applicable.
1 Comparable to the best individual in a current class or research laboratory (upper 5%)
2 Upper 6 to 20%		4 Middle 41 to 60%
3 Upper 21 to 40%		5 Lower 40%
Use black ink.
   Research Ability and Potential				   Originality
   Written and Verbal Communications				   Accuracy
   Perseverance in Pursuing Goals				   Scientific Background
   Self-Reliance and Independence				   Familiarity with Research Literature
   Clinical Proficiency, if relevant				   Ability to Organize Scientific Data
   Laboratory Skills and Techniques, if relevant
Describe your association with the applicant. Comment on the above items, including other areas as appropriate, identifying the strengths and weaknesses that should be considered in evaluating the applicant’s potential for a research career. (Use continuation pages as necessary.)      
DATES ASSOCIATED WITH APPLICANT      			CAPACITY AT THAT TIME (Teacher, dissertation advisor, supervisor, or other) (Use continuation pages as necessary.)      
RESPONDENT (Name, title, department, and institution)      
TELEPHONE NUMBER      	SIGNATURE				DATE      

PHS 416-1 (Rev. 10/08) Reference Page