6B PHS Fellowship Supplemental Form

PHS Fellowship Supplemental Form

OMB Number: 0925-0001

A. Application Type:
From SF424 (R&R) Cover Page. The response provided on that page, regarding the type of application being submitted, is repeated here for your reference as
you provide the responses that are appropriate for this Fellowship application.
New

Resubmission

Renewal

Continuation

Revision

B. Research Training Plan
1. Introduction to Application

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2. * Specific Aims

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3. * Research Strategy

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4. Inclusion Enrollment Report

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5. Progress Report Publication List

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(for RESUBMISSION applications only)

(for RENEWAL applications only)
(for RENEWAL applications only)

Human Subjects
Please note. The following item is taken from the Research & Related Other Project Information form. The response provided on that page, regarding the
involvement of human subjects, is repeated here for your reference as you provide related responses for this Fellowship application. If you wish to change
the answer to the item shown below, please do so on the Research & Related Other Project Information form; you will not be able to edit the response here.
Are Human Subjects Involved?

6. Human Subjects Involvement Indefinite?

Yes

No

7. Agency-Defined Phase III Clinical Trial?

Yes

No

Yes

8. Protection of Human Subjects

No

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9. Inclusion of Women and Minorities

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10. Targeted/Planned Enrollment

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11. Inclusion of Children

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Other Research Training Plan Sections
Please note. The following item is taken from the Research & Related Other Project Information form. The response provided on that page, regarding the
use of vertebrate animals, is repeated here for your reference as you provide related responses for this Fellowship application. If you wish to change the
answer to the item shown below, please do so on the Research & Related Other Project Information form; you will not be able to edit the response here.
Are Vertebrate Animals Used?
12. Vertebrate Animals Use Indefinite?

Yes

Yes

No

No

13. Vertebrate Animals

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14. Select Agent Research

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15. Resource Sharing Plan

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16. * Respective Contributions

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17. * Selection of Sponsor and Institution

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18. * Responsible Conduct of Research

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PHS Fellowship Supplemental Form
C. Additional Information
Human Embryonic Stem Cells
Yes

1. * Does the proposed project involve human embryonic stem cells?

No

If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list:
http://stemcells.nih.gov/research/registry/. Or, if a specific stem cell line cannot be referenced at this time, please check the box indicating that one from the
registry will be used:
Specific stem cell line cannot be referenced at this time. One from the registry will be used.
Cell Line(s):

Fellowship Applicant
2. Alternate Phone Number:
3. Degree Sought During Proposed Award:

If "other", please
indicate degree type:

Degree:

Expected Completion Date
(month/year):
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4. * Field of Training for Current Proposal:
5. * Current Or Prior Kirschstein-NRSA Support?

Yes

No

If yes, please identify current and prior Kirschstein-NRSA support below:
* Level

* Type

Start Date (if known) End Date

(if known) Grant Number

(if known)

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6. * Applications for Concurrent Support?

Yes

No

If yes, please describe in an attached file:

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7. * Goals for Fellowship Training and Career

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8. * Activities Planned Under This Award

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9.

Doctoral Dissertation and Other Research
Experience

10. * Citizenship:

U.S. Citizen or noncitizen national
Permanent Resident of U.S.

(If a permanent resident of the U.S., a notarized statement must be provided by the time of award)

Permanent Resident of U.S. Pending
Non-U.S. Citizen with temporary U.S. visa

PHS Fellowship Supplemental Form
C. Additional Information (continued)
Institution
11.

Change of Sponsoring Institution

Name of Former Institution:

D. Sponsor(s) and Co-Sponsor(s)
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* Sponsor(s) and Co-Sponsor(s) Information

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E. Budget
All Fellowship Applicants:
1. * Tuition and Fees:
None Requested

Funds Requested:
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6 (when applicable)
Total Funds Requested:

Senior Fellowship Applicants Only:
Amount

Academic Period

3. Stipends/Salary During First Year of Proposed Fellowship:
Amount

Number of Months

Amount

Number of Months

a. Federal Stipend Requested:

b. Supplementation from other sources:
Type (sabbatical leave, salary, etc.)

Source

F. Appendix

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Number of Months
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2. Present Institutional Base Salary:

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