21 Personal

Program Director/Principal Investigator (Last, First, Middle):					     
Place this form at the end of the signed original copy of the application. Do not duplicate.
PERSONAL DATA ON PROGRAM DIRECTOR(S)/PRINCIPAL INVESTIGATOR(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 program director(s)/principal investigator(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 PDs/PIs 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)			     			SEX/GENDER Female Male
SOCIAL SECURITY NUMBER (last 4 digits only)			XXX-XX-	     
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. 09/07) DO NOT PAGE NUMBER THIS FORM Personal Data Form Page