3 Recommender and Institution Contacts

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Loan Repayment Programs
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OMB No. 0925-0361
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Recommendation

NIH 2674-13
LRP Tracking Code:

Important: Please note that the applicant did not waive future access to this information. Therefore, the information you provide
cannot be protected from disclosure.
Important: Please note that the applicant waived future access to this information. Therefore, the information you provide shall be
held in confidence and protected from disclosure by officials of the NIH Loan Repayment Programs according to Privacy
Act System of Records #09-25-0165.
Section 1 - Applicant Information

Name:
Applicant's Organization:
Loan Repayment Program (LRP)
Applied For:

Section 2 - Recommendation
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form, unless you click Save and Continue or Submit button.  The 30 minute time-out resets each time you click the Save
and Continue button.  Please periodically click SAVE & CONTINUE in order to not lose work in progress.
Instructions:  All fields on this form are required and all text fields have size limits. You may elect to cut and paste text
from another document into the text fields.
If you have no further information to add to a question, please indicate "No Comment" or "N/A".
Relationship to Applicant
In what capacity do you know the
applicant?
(Please limit your response to 100 characters or less.)

How long have you known the
applicant?
(Please limit your response to 50 characters or less.)

Rating of Applicant

Select the rating that best indicates your assessment of the applicant in relation to his/her
peers.

Previous training and experience to
prepare for a pediatric* research
career:

1 (Outstanding)

2

3

4

5

6

7 (Poor)      

(Don't Know)

Career goals and plans to achieve
these goals:

1 (Outstanding)

2

3

4

5

6

7 (Poor)      

(Don't Know)

Commitment to a career in
pediatric* research:

1 (Outstanding)

2

3

4

5

6

7 (Poor)      

(Don't Know)

Potential for a career in
pediatric* research:

1 (Outstanding)

2

3

4

5

6

7 (Poor)      

(Don't Know)

Likelihood to become an
independent researcher:

1 (Outstanding)

2

3

4

5

6

7 (Poor)      

(Don't Know)

Potential for success in research or
academic medicine:

1 (Outstanding)

2

3

4

5

6

7 (Poor)      

(Don't Know)

Overall Assessment of Applicant
What are the main strengths and
assets that the applicant brings to
his/her research environment?

Text hidden if Renewal: What are (Please limit your response to 2500 characters (approximately 1/2 page) or less.)
the weaknesses that might limit the
applicant's effectiveness in
conducting research (basic science
or pediatric* research)?

Text hidden if New: Assess the
applicant's accomplishments over
the past two years and what
advantages will be conferred by an
(Please limit your response to 2500 characters (approximately 1/2 page) or less.)
additional year of continued
research experience?
What is your overall
recommendation for the applicant?

1 (High)

2

3

4

5

6

7 (Do Not Recommend)      

(Please limit your response to 2500 characters (approximately 1/2 page) or less.)

*text changes based on LRP
Section 3 - Recommenders Certification
I certify that the statements herein are true, accurate and complete. 
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this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIH, Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674-13
Privacy Act 09-25-0165

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