Form 2 PHS 416-9

Form Approved Through 06/30/2015

OMB No. 0925-0002
Review Group

Department of Health and Human Services
Public Health Service

Ruth L. Kirschstein
National Research Service Award
Individual Fellowship Progress Report
Follow instructions carefully

Type

Activity

Fellowship Number

Total Project Period
From:

Through:

Requested Budget Period
From:

Through:

1. TITLE OF RESEARCH TRAINING PROPOSAL
2a. FELLOW (Name and address, street, city, state, zip code)

2b. FELLOW’S E-MAIL ADDRESS
2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
2d. MAJOR SUBDIVISION

3a. NAME OF SPONSOR

3b. SPONSOR’S E-MAIL ADDRESS

4. SPONSORING INSTITUTION (Name and address, street, city,
state, zip code)

6a. TITLE AND ADDRESS OF OFFICIAL IN SPONSORING
INSTITUTION BUSINESS OFFICE

5. ENTITY IDENTIFICATION NO.

6b. E-MAIL ADDRESS:

7. HUMAN SUBJECTS
7a. Research
Exempt
NO
YES

NO

9. TRAINING SITE(S) (Organizations and addresses)

YES

If Exempt ("Yes" in 7a): Exemption No.

Organizational Name:

If Not Exempt ("No" in 7a): IRB approval date

DUNS:

7b. Federalwide Assurance No.

Street 1:

7c. NIH Defined Phase III Clinical Trial

NO

YES

8. VERTEBRATE ANIMALS

NO

YES

8a. If “Yes,”
IACUC approval date

8b. Animal welfare assurance no.

10. NAME AND TITLE OF OFFICIAL SIGNING FOR APPLICANT
ORGANIZATION (Item 13)
NAME

City:

County:

State:

Province:

Country:

Zip/Postal Code:

Congressional Districts:
11. FELLOW’S TELEPHONE INFORMATION

TITLE
TEL

Street 2:

OFFICE
FAX

E-MAIL

FAX
HOME

12. CORRECTIONS (Items 1 - 6)

13. 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 Public Health Service terms and conditions if a grant is awarded as a
result of this report. 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 10.
(In ink. “Per” signature not acceptable.)
PHS 416-9 (Rev. 06/12)

DATE
Form Page 1

Program Director/Principal Investigator (Last, First, Middle):

Use only if additional space is needed to list additional project/performance sites.
Additional Project/Performance Site Location
Organizational Name:
DUNS:
Street 1:

Street 2:

City:
Province:

County:

State:

Country:

Zip/Postal Code:

Project/Performance Site Congressional Districts:

Additional Project/Performance Site Location
Organizational Name:
DUNS:
Street 1:

Street 2:

City:
Province:

County:

State:

Country:

Zip/Postal Code:

Project/Performance Site Congressional Districts:

Additional Project/Performance Site Location
Organizational Name:
DUNS:
Street 1:

Street 2:

City:
Province:

County:

State:

Country:

Zip/Postal Code:

Project/Performance Site Congressional Districts:

Additional Project/Performance Site Location
Organizational Name:
DUNS:
Street 1:

Street 2:

City:
Province:

County:

State:

Country:

Zip/Postal Code:

Project/Performance Site Congressional Districts:

Additional Project/Performance Site Location
Organizational Name:
DUNS:
Street 1:

Street 2:

City:
Province:

County:
Country:

State:
Zip/Postal Code:

Project/Performance Site Congressional Districts:

PHS 416-9 (Rev. 06/12)6/09

Page

Project/Performance Site Format Page

Ruth L. Kirschstein National Research Service Award

FELLOWSHIP NUMBER

Individual Fellowship Progress Report for
Continuation Support

14a. PERMANENT MAILING ADDRESS OF FELLOW (Street, city, state,
zip code)

14b. PERMANENT PHONE NUMBER

15. Human subjects, vertebrate animals, select agents and human embryonic stem cells (see instructions)
A. Human Subjects (Complete Item 7 on the Face Page)
Use of Human Subjects

Change

No Change Since Previous Submission

B. Vertebrate Animals (Complete Item 8 on the Face Page)
Use of Vertebrate Animals

Change

No Change Since Previous Submission

C. Select Agents (There is no item required on Face Page for Select Agents)
Use of Select Agents

Change

No Change Since Previous Submission

D. Human Embryonic Stem Cells (There is no item required on Face Page for Human Embryonic Stem Cells)
Human Embryonic Stem Cell Line(s) Used

Change

No Change Since Previous Submission

WOMEN AND MINORITY INCLUSION IN CLINICAL RESEARCH
See SF424 (R&R) Fellowship Application Guide Instructions. Use Inclusion Enrollment Report Format Page and, if necessary, Targeted/Planned
Enrollment Format Page.

16. SUMMARY OF ACTIVITIES (Use continuation pages. Do not exceed 3 pages.)
A. CHANGES
Since submission of the last application/progress report, have any significant changes occurred in the training program, particularly the
research project, academic status, or time distribution of activities (i.e., percentage of time devoted to research project, course work,
teaching, etc.)? If so, explain.
B. PROGRESS
Describe concisely the research performed and research training obtained, including instruction in the responsible conduct of research,
during the past year. List all courses and publications.
Complete the Inclusion Enrollment Report Format Page and Targeted/Planned Enrollment Format Page, if applicable.
C. RESEARCH TRAINING PLANS
Describe concisely the research and research training planned for the requested budget period, including any course work.

PHS 416-9 (Rev. 606/12)

Page

Form Page 2

Name of Applicant (Last, first, middle):

Inclusion Enrollment Report
This report format should NOT be used for data collection from study participants.
Study Title:
Total Enrollment:

Protocol Number:

Grant Number:
PART A. TOTAL ENROLLMENT REPORT:

Ethnic Category

Number of Subjects Enrolled to Date (Cumulative)
by Ethnicity and Race
Sex/Gender
Unknown or
Females
Males
Not Reported

Total

Hispanic or Latino

**

Not Hispanic or Latino
Unknown (individuals not reporting ethnicity)

*

Ethnic Category: Total of All Subjects*
Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Unknown or Not Reported

*

Racial Categories: Total of All Subjects*

PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics or Latinos Enrolled to Date (Cumulative)

Racial Categories

Females

Males

Sex/Gender
Unknown or
Not Reported

Total

American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Unknown or Not Reported

**

Racial Categories: Total of Hispanics or Latinos**
* These totals must agree.

** These totals must agree.

PHS 416-9 (Rev. 06/12)

Page

Inclusion Enrollment Report Format Page

Name of Applicant (Last, first, middle):

Targeted/Planned Enrollment Table
This report format should NOT be used for data collection from study participants.
Study Title:
Total Planned Enrollment:
TARGETED/PLANNED ENROLLMENT: Number of Subjects
Ethnic Category

Females

Males

Total

Hispanic or Latino
Not Hispanic or Latino
Ethnic Category: Total of All Subjects *
Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Racial Categories: Total of All Subjects *
* The “Ethnic Category: Total of All Subjects” must be equal to the “Racial Categories: Total of All Subjects.”

PHS 416-9 (Rev. 06/12)

Page

Targeted/Planned Enrollment Table Format Page

Ruth L. Kirschstein National Research Service Award

FELLOWSHIP NUMBER

Individual Fellowship Progress Report for
Continuation Support

(To be completed by sponsor  follow PHS 416-9 instructions)
If “yes,” specify the amount(s) and dates on which supplementation
17. SUPPLEMENTATION OF STIPEND:
NO
YES
occurred, and the source of the funds.

18. COMMENTS OF SPONSOR (Use additional page, if necessary)
Evaluate the quality of the training (including academic work) and research progress made by the fellow during the past year. Include
performance on cumulative and qualifying examinations, if applicable.

APPLICANT ORGANIZATION’S ASSURANCES/CERTIFICATIONS
In signing the application Face Page, the applicant organization official agrees to comply with the policies, assurances and/or certifications listed in
the application instructions when applicable. Descriptions of individual assurances/certifications are provided in the PHS 416-9 Instructions under
Section 2.1, Item 13. Applicant Organization Certification and Acceptance. If unable to certify compliance, where applicable, provide an explanation
and place it after the Progress Report.
PHS 416-9 (Rev. 06/12)

Page

Form Page 3

Click for More Info on This Form

Name of Applicant (Last, First, Middle):

PHS 416-9 (Rev. 06/12)

Page

Continuation Format Page