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pdfKirschstein−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
File Type | application/pdf |
File Title | PHS 416-1fp3 (Rev. 6/12), Form Page 3 |
Subject | Ruth L. Kirschstein National Research Service Award Individual Fellowship Application, PHS 416-1fp3 (Rev. 6/12), Form Page 3 |
Author | DHHS, Public Health Service |
File Modified | 2012-05-03 |
File Created | 2008-09-10 |