Intramural/ Renewal Applications

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

NATIONAL INSTITUTES OF HEALTH

Loan Repayment Programs

Instructions for Application Package: NIH 2674

Purpose of application forms:

The purpose of the online application is to gather the necessary information and certifications that allow NIH to properly evaluate your eligibility for the NIH Loan Repayment Program (LRP) you have applied for, to review your application for it’s appropriateness to the program, and to make funding decisions. More detailed instructions are contained on each of the online forms. If you have any questions on the application, you may call the NIH LRP Information Center at 866 849-4047.

You must complete all required forms as incomplete applications will not be reviewed.

Forms:

2674-1 Applicant Information

Please provide us with your contact, employment, educational, other service obligation, federal affiliations, and other information. You are required to attach a copy of their Biosketch. This information will be used to contact you and determine eligibility. In addition, you may optionally provide us with information on Gender/Race/National Origin/Disability Status. This form is required for all applicants.

2. Personal Statement

The purpose of this form is to describe your previous research training experience, short-term academic and research objectives, long-term career objectives and plan to achieve these objectives. This information is used by NIH Peer Review when evaluating your commitment to a career in research and the appropriateness of your previous training and experience as preparation for a career in clinical research. This form is required for all applicants.

2. Recommendations

Please use this form to identify the colleagues that will provide a recommendation. The application process requires each applicant to obtain at least 3 completed recommendations, however, we allow you to identify up to 5 recommenders. All completed recommendations are forwarded to NIH for review. This form is required for all applicants except for Intramural Renewal applicants.

2. Loan Information Form

The purpose of this form is for you to identify the outstanding educational debt. All New LRP applicants are required to complete one or more form providing detailed information on their qualifying educational loans. This information is used to determine eligibility and to verify that the loan qualifies for repayment. If your application is selected for funding, yous will be required to fax us copies of their Promissory Note and a current Loan Statement for each loan identified on the Loan Information form(s). This form is required for all New applicants.

2. IC Recommendation for LRP Funding

This form is completed by Loan Repayment Coordinator at NIH for all Intramural applicants. It provides information on the employment of the applicant which is used to verify eligibility for the program. It is required for all Intramural applicants.

2. Research Activities

Please use this form to upload a document outlining your specific research project during the term of the LRP contract. Applicants must describe the research activities they will pursue over the next contract period, their specific responsibilities, and their role in the research. If applicants are working with a Research Supervisor or Principal Investigator, they will provide us with their name and email address as they are required to complete a recommendation and an assessment of research activities form. If applicants do not have a Research Supervisor or Principal Investigator (Independent researcher), they will need to provide us with a document outlining the Research Environment and another document outlining their Career Development Plan. This form is required for all applicants.

2. Assessment of Research Activities

This form is completed by the specified Research Supervisor or Principal Investigator, if one was designated. Research Supervisors will provide their Biosketch, a document outlining the Research Environment, your Training and Mentoring Plan, and be provided the opportunity to upload the biosketch of a colleague that is also involved in the applicant’s mentoring and training. This form is required for all applications.

2. Research Accomplishments

As a renewal applicant, you are required to document their research accomplishments during the prior contract period. If you have recently changed your research project or research supervisor, you will need to provide us with contact information of the colleague who can best speak to your accomplishments. This form is only required for Renewal applicants.

2. Certifications for Online Applications

Please print, review, and sign this form (in 3 locations) and fax the completed form to our office at 866 849-4046. This form is used for you to certify to the accuracy of the information provided in the application, allow us to obtain information on the loans, and address the confidentiality of the recommendations. This form is required for all applicants.

2. Institutional Contact

Please provide us with the name and email address of the institutional representative that can certify to your support for the designated research over the term of the contract. The official providing this information should be someone authorized to reply for the organization. Common titles for this individual are dean, associate dean, provost or chancellor of research & sponsored programs, or vice president of research administration. Applicants that are not certain whom to name, please consult with their research supervisor or principal investigator. This is required for all applicants.

2. Disadvantaged Background Documentation

This form is only completed for individuals that have applied for the Clinical Research for Individuals from Disadvantaged Background LRP. You need to print the form, identify the criteria under which you qualify for this program and fax the form along with the required documentation to our office at 866 849-4046.

To meet this low-income requirement you must demonstrate your disadvantaged status by submitting (1) a written statement from your former school(s) where you qualified for Federal disadvantaged assistance, (2) verification of receipt of loans from either the Health Professions Student Loans (HPSL) or Loans for Disadvantaged Student Program, or (3) verification of a scholarship from the U.S. Department of Health and Human Services under the Scholarship for Individuals with Exceptional Financial Need.

This form is required for any applicant that applied for the Clinical Research for Individuals from Disadvantaged Background LRP.

2. Contract

You are required to read, sign and return the contract. Please mail the original contract to:

National Institutes of Health

Office of Loan Repayment

6011 Executive Boulevard, Room 206

Bethesda, Maryland 20892-7650

This contract is required for all applicants.

2. Recommendation

This form will be completed by the colleagues you listed on Form 2674-3. An applicant to the NIH LRP program has listed you as a recommender. Please complete/update your contact information, and then provide us with your ratings regarding this applicant’s research capabilities, and provide your narrative assessment of the applicant in the three sections provided. This form is required for all applicants.

2. Assessment of Research Accomplishments

This form will be complete by the Research Supervisor or Principal Investigator you identified on Form 2674-6. An applicant to the NIH LRP program has listed you as their research supervisor. Please complete/update your contact information, review the attached research accomplishments document provided by the applicant and then provide us with a document outlining their research accomplishments.

15. Apply Here

Please use this form to register your email and set up your password and provide the information needed to start your application. The email address you provide will be used to contact you during the application cycle. NIH needs your SSN to verify your identity, determine your eligibility for loan repayment assistance and the amount of assistance, and keep track of the Federal funds you receive. NIH also uses your SSN for loan repayment and servicing purposes. See Privacy Act information in this package. You need to identify if you are applying to the Extramural Program (for Non-NIH researchers) or Intramural Program (for NIH researchers); which LRP you are apply for; if you are a New applicant or Renewal Applicant; and if you will be identifying a Research Supervisor. If you are an Intramural applicant, you will need to provide your title and the hiring NIH institute or center. This form is required for all applicants.

15. Institutional Information

This form will be complete by the Institutional Contact you identified on Form 2674-10. An applicant to the NIH LRP program has listed you as their institutional contact. Please complete/update your contact information. You are asked to provide us with their salary and to certify to the source of their funding and certify that your institution will provide the necessary support for the applicant to conduct their research for the duration of the contract. For New applicants, the initial period will be for two years beginning in July of the upcoming year. For Renewal applicants, you are allowed to certify to one (1) or two (2) years of additional support for the applicant. This certification is required for all Extramural applicants.

15. Loan Information Form

Please complete this form providing us with current information on the specified loan. You will be asked to complete one form for each of the applicant’s loans. The completed forms may be faxed to NIH LRP at 866 849-4046 or mailed to us at:

National Institutes of Health

Office of Loan Repayment

6011 Executive Boulevard, Room 206

Bethesda, Maryland 20892-7650

This form is only used to obtain further information on existing loans or when applicants need to add loans to their portfolio.

2674-18 Citizenship Information

The NIH LRP is available to U.S. Citizens and U. S. Permanent Residents. Please complete the form verifying your citizenship status, then print the fax cover sheet and fax it to us at 866 849-4046 along with the source document you identified on the form which documents your citizenship status. This form is required for all Extramural New applicants.

2674-19 Funding Information

Please use this form to list the top three (3) non-profit source(s) of the funding that will support your research activities over the term of the LRP contract. If your research is supported by grants it is not necessary for you to be named on the grant to include the grant information. If your non-profit employer is one of your top three non-profit funding sources list your non-profit employer in Section 1 as well as any other Non-Profit funding source.  If you are supported by a current or future National Research Service Awards (NRSA Fellowship), please list it in Section 2. If you are supported by an NIH Grant, please list it in Section 3.

At least one non-profit or NIH funding source must be identified.  Funding information will be used for NIH program evaluation only. The source of your funding will not be used in the review of your application. This form is required for all Extramural applicants.

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