7B Face Page

** PHS 416-1 IS TO BE USED ONLY FOR A CHANGE OF SPONSORING INSTITUTION APPLICATION **
COMPETING NEW, RENEWAL OR RESUBMISSION FELLOWSHIP APPLICATIONS MUST USE THE SF424 (R&R)
FELLOWSHIP APPLICATION PACKAGE AND APPLICATION GUIDE FOR ELECTRONIC SUBMISSION VIA
GRANTS.GOV. ANY NEW, RENEWAL OR RESUBMISSION APPLICATION SUBMITTED USING THE PHS 416-1
WILL BE RETURNED AND NOT REVIEWED.
Form Approved Through 06/30/2015

OMB No. 0925-0001
LEAVE BLANK—For PHS use only.

Department of Health and Human Services
Public Health Service

Ruth L. Kirschstein National Research Service Award

Type

Activity

Number

Individual Fellowship Application

Review Group

Formerly

Follow instructions carefully.
Do not exceed character length restrictions indicated.

Meeting Dates

Date Received

1. TITLE OF RESEARCH TRAINING PROPOSAL (Do not exceed 81 characters, including spaces and punctuation.)

2. LEVEL OF FELLOWSHIP

3. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT
(If “Yes,” state number and title)
Number:
Title:

4a. NAME OF APPLICANT (Last, First, Middle)

4b. ERA COMMONS USER NAME

4d. PRESENT MAILING ADDRESS (Street, City, State, Zip Code)

NO

YES

4c. HIGHEST DEGREE(S)

4e. PERMANENT MAILING ADDRESS (Street, City, State, Zip Code)

4f. E-MAIL ADDRESS:
TELEPHONES AND FAX (Area code, number and extension)
4g. OFFICE
4k.

4h. HOME

4i. PERMANENT

4j. FAX NUMBER

U.S. CITIZEN OR U.S. NONCITIZEN NATIONAL

PERMANENT RESIDENT OF U.S. PENDING

PERMANENT RESIDENT OF U.S.

NON-U.S. CITIZEN WITH TEMPORARY U.S. VISA

5. TRAINING UNDER PROPOSED AWARD (See Fields of Training)
Discipline No.: Subcategory Name:
7a. DATES OF PROPOSED AWARD
From (MM/DD/YY): Through (MM/DD/YY):
9. HUMAN SUBJECTS
RESEARCH
No
Yes
Indefinite

6. PRIOR AND/OR CURRENT NRSA SUPPORT
(Individual or Institutional)
NO
YES (If “Yes,” refer to item 22, Form Page 5)

7b. PROPOSED AWARD DURATION
(in months)

9b. Federalwide Assurance No.
9c. Clinical Trial
No
Yes

9a. Research Exempt
If “Yes,” Exemption No.

No

9d. NIH-defined Phase III
Clinical Trial
No

8. DEGREE SOUGHT DURING PROPOSED AWARD
Degree:
Expected Completion Date:

10. VERTEBRATE ANIMALS

No

Yes

10a. Animal Welfare Assurance No.
Yes

Yes

11. SPONSORING INSTITUTION

13. OFFICIAL SIGNING FOR SPONSORING INSTITUTION

Name

Name

Address

Title
Address

12a. ENTITY IDENTIFICATION NO.

12b. DUNS NO.

Tel:

Fax:

E-Mail:
14. 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 terms and conditions of award if an award is issued as a result of this application. I am aware that any false,
fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.
SIGNATURE OF OFFICIAL NAMED IN 13.
(In ink. “Per” signature not acceptable.)

PHS 416-1 (Rev. 6/12)

DATE

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Form Page 1