4040-0001 R&R Personal Data

OMB Number: 4040-0001
Expiration Date: 06/30/2011

RESEARCH & RELATED PERSONAL DATA
Project Director/Principal Investigator and Co-Project Director(s)/Co-Principal Investigator(s)
The Federal Government has a continuing commitment to monitor the operation of its review and award processes to identify and address any inequities
based on gender, race, ethnicity, or disability of its proposed PDs/PIs and co-PDs/PIs. To gather information needed for this important task, the
applicant should submit the requested information for each identified PD/PI and co-PDs/PIs with each proposal. Submission of the requested
information is voluntary and is not a precondition of award. However, information not submitted will seriously undermine the statistical validity, and
therefore the usefulness, of information received from others. Any individual not wishing to submit some or all the information should check the box
provided for this purpose. Upon receipt of the application, this form will be separated from the application. This form will not be duplicated, and it will not
be a part of the review process. Data will be confidential.
Project Director/Principal Investigator
Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

Gender:
Race (check all that apply):

Ethnicity:

Disability Status (check all that apply):

American Indian or Alaska Native

Hearing

Asian

Visual

Black or African American

Mobility/Orthopedic Impairment

Native Hawaiian or Other Pacific Islander

Other

White

None

Do Not Wish to Provide

Do Not Wish to Provide

Citizenship: