7G Checklist Form Page

NAME OF APPLICANT (Last, first, middle initial)

Kirschstein−NRSA Individual Fellowship Application

Checklist
To be completed by Applicant
A. TYPE OF APPLICATION
NEW application (This application is being submitted to the PHS for the first time.)
RESUBMISSION of application number
(This application replaces a prior unfunded version of a new or renewal application.)
RENEWAL of award number
(This application is to extend a funded award beyond its current award period.)
CHANGE of Sponsoring Institution

Name of former
Institution:

B. ASSURANCES/CERTIFICATIONS
In signing the application Face Page, the authorized organizational representative agrees to comply with the policies, assurances and/or
certifications listed in the application instructions when applicable. Descriptions of individual assurances/certifications are provided in Part III, and
listed in Part I. If unable to certify compliance, where applicable, provide an explanation and place it after this page.
C. KIRSCHSTEIN−NRSA SENIOR FELLOWSHIP APPLICANTS ONLY
1.

PRESENT INSTITUTIONAL BASE SALARY

Amount

2.

Academic Period/number of months

STIPEND/SALARY DURING FIRST YEAR OF PROPOSED FELLOWSHIP
a. Stipend requested from PHS

Amount
Number of months

b. Supplementation from other sources

Amount

Number of months

Type (sabbatical leave, salary, etc.)

Source

D. TUITION and FEES
Predoctoral applicants should list estimated combined costs of tuition and fees. Postdoctoral applicants should list the estimated costs for the
tuition and fees for courses planned that support the research training experience. For postdoctoral applicants, those courses should be
described under Section D. Research Design and Methods of the Research Training Plan. Health insurance for predoctoral and postdoctoral
fellowships is now paid as part of the institutional allowance. Senior Fellowship applicants should omit this section.
None Requested
Funds Requested:
Year – 01

PHS 416-1 (Rev. 6/12)

Year – 02

Year – 03

Page

Year – 04

Year – 05

Year – 06
(when applicable)

Checklist Form Page