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pdf** PHS 416-1 IS TO BE USED ONLY FOR A CHANGE OF SPONSORING INSTITUTION APPLICATION **
COMPETING NEW, RENEWAL OR RESUBMISSION FELLOWSHIP APPLICATIONS MUST USE THE SF424 (R&R)
FELLOWSHIP APPLICATION PACKAGE AND APPLICATION GUIDE FOR ELECTRONIC SUBMISSION VIA
GRANTS.GOV. ANY NEW, RENEWAL OR RESUBMISSION APPLICATION SUBMITTED USING THE PHS 416-1
WILL BE RETURNED AND NOT REVIEWED.
Form Approved Through 06/30/2015
OMB No. 0925-0001
LEAVE BLANK—For PHS use only.
Department of Health and Human Services
Public Health Service
Ruth L. Kirschstein National Research Service Award
Type
Activity
Number
Individual Fellowship Application
Review Group
Formerly
Follow instructions carefully.
Do not exceed character length restrictions indicated.
Meeting Dates
Date Received
1. TITLE OF RESEARCH TRAINING PROPOSAL (Do not exceed 81 characters, including spaces and punctuation.)
2. LEVEL OF FELLOWSHIP
3. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT
(If “Yes,” state number and title)
Number:
Title:
4a. NAME OF APPLICANT (Last, First, Middle)
4b. ERA COMMONS USER NAME
4d. PRESENT MAILING ADDRESS (Street, City, State, Zip Code)
NO
YES
4c. HIGHEST DEGREE(S)
4e. PERMANENT MAILING ADDRESS (Street, City, State, Zip Code)
4f. E-MAIL ADDRESS:
TELEPHONES AND FAX (Area code, number and extension)
4g. OFFICE
4k.
4h. HOME
4i. PERMANENT
4j. FAX NUMBER
U.S. CITIZEN OR U.S. NONCITIZEN NATIONAL
PERMANENT RESIDENT OF U.S. PENDING
PERMANENT RESIDENT OF U.S.
NON-U.S. CITIZEN WITH TEMPORARY U.S. VISA
5. TRAINING UNDER PROPOSED AWARD (See Fields of Training)
Discipline No.: Subcategory Name:
7a. DATES OF PROPOSED AWARD
From (MM/DD/YY): Through (MM/DD/YY):
9. HUMAN SUBJECTS
RESEARCH
No
Yes
Indefinite
6. PRIOR AND/OR CURRENT NRSA SUPPORT
(Individual or Institutional)
NO
YES (If “Yes,” refer to item 22, Form Page 5)
7b. PROPOSED AWARD DURATION
(in months)
9b. Federalwide Assurance No.
9c. Clinical Trial
No
Yes
9a. Research Exempt
If “Yes,” Exemption No.
No
9d. NIH-defined Phase III
Clinical Trial
No
8. DEGREE SOUGHT DURING PROPOSED AWARD
Degree:
Expected Completion Date:
10. VERTEBRATE ANIMALS
No
Yes
10a. Animal Welfare Assurance No.
Yes
Yes
11. SPONSORING INSTITUTION
13. OFFICIAL SIGNING FOR SPONSORING INSTITUTION
Name
Name
Address
Title
Address
12a. ENTITY IDENTIFICATION NO.
12b. DUNS NO.
Tel:
Fax:
E-Mail:
14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete, and accurate to the best of
my knowledge, and I agree to comply with the terms and conditions of award if an award is issued as a result of this application. I am aware that any false,
fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.
SIGNATURE OF OFFICIAL NAMED IN 13.
(In ink. “Per” signature not acceptable.)
PHS 416-1 (Rev. 6/12)
DATE
Face Page
Form Page 1
File Type | application/pdf |
File Title | PHS 416-1fp1 (Rev. 6/12), Face Page, Form Page 1 |
Subject | Ruth L. Kirschstein National Research Service Award Individual Fellowship Application PHS 416-1fp1 (Rev. 6/12), Face Page, Form |
Author | DHHS, Public Health Service |
File Modified | 2012-05-03 |
File Created | 2009-07-29 |