7E Face Page 4

Kirschstein−NRSA Individual Fellowship Application

NAME OF APPLICANT (Last, first, middle initial)

Table of Contents
Page Numbers
(Number pages consecutively at the bottom throughout
the application. Do not use suffixes such as 6a, 6b.)

Section I — Applicant/Fellow

Face Page ...................................................................................................................................
Sponsor’s Contact Information, Description (Form Page 2) .................................................
Training & Career Goals, Activities Planned Under This Award, Training Site(s),

Human Embryonic Stem Cells (Form Page 3) ....................................................................

Table of Contents (Form Page 4) .............................................................................................

Biographical Sketch – Applicant/Fellow (Not to exceed four pages) .........................................

Previous Research Experience (Form Page 5) .......................................................................

Research Training Plan

1. Introduction to Resubmission Application (not to exceed 1 page) ........................................

2. Specific Aims .....................................................................................................................

3. Background/Significance ............................. (Items 2-5 not to exceed 10 pages).............

4. Preliminary Studies/Progress Report ………………………………………………………….
5. Research Design and Methods .........................................................................................

6. Inclusion Enrollment Report (for Renewal applications only) ................................................

7. Progress Report Publication List (for Renewal applications only) .........................................

8. Human Subjects (Required if Item 9 on the Face Page is marked “Yes”) ....................................

9. Clinical Trial ......................................................................................................................

10. Agency-Defined Phase III Clinical Trial ............................................................................

11. Protection of Human Subjects (Required if Item 9 on the Face Page is marked “Yes”) ............

12. Inclusion of Women and Minorities (Required if Item 9 on the Face Page is marked “Yes”

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and is Clinical Research) ................................................................................................................

Targeted/Planned Enrollment Table (for new and continuing clinical research studies) ...........

Inclusion of Children (Required if Item 9 on the Face Page is marked “Yes”) .............................

Vertebrate Animals (Required if Item 10 on the Face Page is marked “Yes”) .................................

Select Agent Research ......................................................................................................

Bibliography and References Cited (formerly "Literature Cited") ......................................

Resource Sharing ..............................................................................................................

Respective Contributions...................................................................................................

Selection of Sponsor and Institution ..................................................................................

Responsible Conduct of Research ....................................................................................

Section II — Sponsor’s/Co-Sponsor’s Information

Biographical Sketch--Sponsor .................................................................................................

Research Support Available ........................................................................................................

Previous Fellows/Trainees...........................................................................................................

Training Plan, Environment, Research Facilities .........................................................................

Number of Fellows/Trainees to be Supervised............................................................................

Applicant’s Qualifications and Potential.......................................................................................

Checklist (Completed by Fellow/Applicant & Sponsoring Institution).........................................

Section III — Letters of Reference (Minimum of 3)

(See instructions for submission of references.)
List full name, institution, and department of individuals submitting reference letters.

Other Items (list):

Personal Data Page for Fellowship Applicants

Appendix

Appendix (Five identical CDs)

PHS 416-1 (Rev. 6/12)

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