7C Face Page 3

Kirschstein−NRSA Individual Fellowship Application

NAME OF APPLICANT (Last, first, middle initial)

(To be completed by applicant – follow PHS 416-1 instructions)
18. GOALS FOR KIRSCHSTEIN−NRSA FELLOWSHIP TRAINING AND CAREER

19. ACTIVITIES PLANNED UNDER THIS AWARD: Approximate percentage of proposed award time in activities identified below. (See instructions.)
Year

Research

Course Work

Teaching

Clinical

First
Second
Third

PREDOCTORAL FELLOWSHIPS ONLY
Fourth
Fifth

MD/PhD FELLOWSHIPS ONLY
Sixth
Briefly explain activities other than research and relate them to the proposed research training.

20. TRAINING SITE(S) Is the Primary Training Site the same as the Sponsoring Institution?

Yes

No

If No, provide detailed information below for the Primary Training Site Location
Organizational Name:
DUNS:
Street 1:

Street 2:

City:
Province:

County:

State:

Country:

Zip/Postal Code:

Project/Performance Site Congressional Districts:
21. HUMAN EMBRYONIC STEM CELLS

No

Yes

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/eligibilityCriteria.asp. Use continuation pages as needed.
If a specific line cannot be referenced at this time, include a statement that one from the Registry will be used.

Cell Line

PHS 416-1 (Rev. 6/12)

Page 3

Form Page 3