2 Advisors and Supervisors

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Loan Repayment Programs
866-849-4047 | [email protected]

OMB No. 0925-0361
Form Approved for use through X/X/X
Click here to see the burden statement

Assessment of Research Activity

NIH 2674-7
LRP Tracking Code:

Applicant Identifying Information
Applicant's Name:
Organization:

Section 1 - Concur with Applicant's Research Project Description
Instructions: The applicant has provided the statement linked below describing his/her research project. Please review this
statement and indicate your concurrence by checking the box below. You may submit a revised file by uploading a new
document. Caution:  If you upload a new file, that file will replace the document the applicant uploaded.    Please note that the
length is limited to 20,000 characters or less including spaces (approximately five single-spaced typed pages plus one page for
references).
Research Project Title:

Review Statement:
  Click here to view applicant's statement
Principal Investigator/Research Supervisor
Concurrence:

Upload New Research Project, if
necessary:

I concur with this statement
I wish to replace the applicant's statement with a new attachment.

Attach File: 

no file selected
Instructions: Click
the "Browse" button
and locate your file.
We accept most file
types.

Section 2 - Description of Applicant's Research Environment
Instructions: Use 5,000 characters or less (approximately one typed page) to describe the current research conducted in the
branch/laboratory/section/department of the applicant and the availability of appropriate scientific colleagues, institutional research,
and facilities. You should also include a brief description of the source of funding for the research the applicant is engaged in as
well as your funding sources.

Please attach a file describing the research
environment:

Attach File: 

no file selected

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Section 3 - Applicant's Research Training/Mentoring/Career Development Plan
Instructions: Use 5,000 characters or less (approximately one typed page) to detail the applicant's research training program and
mentoring plan. Specify the types of training interactions the applicant will have with you, what training mechanisms will be used,
what research methods and scientific techniques will be learned, what journal clubs or groups the applicant will join, and what
conferences and seminars the applicant will attend. If another laboratory staff member will be involved in the mentoring program,
please provide his/her name and describe his/her degree of involvement. Please include a summary of your prior experience as a
mentor of other investigators.
Please attach a file describing the
applicant's research
training/mentoring/career development plan:

Attach File:
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If another laboratory staff member will be
involved in the mentoring program, please
provide his/her Biosketch:

no file selected
Attach File:
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Click here for
instructions on
completing a
Biosketch and for
a sample Biosketch
in PDF or Rich
Text Format
(rtf).  Do not
exceed 5 pages.

Section 4 - Biosketch of Principal Investigator/Research Supervisor
Please submit your Biosketch:

Attach File:
no file selected
File successfully uploaded. View it

Click here for
instructions on
completing a
Biosketch and for
a sample Biosketch
in PDF or Rich
Text Format
(rtf).  Do not
exceed 5 pages.

Section 5 -  Principal Investigator/Research Supervisor Assurance
✔

I certify that (1) the statements herein are true, complete, and accurate to the best of my knowledge; (2) I agree to accept
responsibility for the scientific conduct of the research project; (3) I certify that the applicant, named in Section 1 of this form,
will be provided the necessary time and resources to engage in the named research project if a Loan Repayment contract is
awarded and (4) I also agree to provide periodic (usually quarterly) service verifications on behalf of this applicant if a Loan
Repayment contract is awarded. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to
criminal, civil, or administrative penalties.

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Submit Form

Public reporting for this collection of information is estimated to average 30 minutes, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information, unless is displays a currently valid OMB control number. Send comments regarding
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 2674-7
Privacy Act 09-25-0165

Please periodically click SAVE & CONTINUE in order to not lose
work in progress. You will automatically be logged off the LRP
Web site if you have not moved to a new page in any one hour
time period.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

OMB No. 0925-0361
Form Approved for use through X/X/X
Click here to see the burden statement

Assessment of Research Accomplishments

NIH 2674-14
LRP Tracking Code:

Instructions:  Please use 5000 characters or less including spaces (approximately one typed page) to provide an assessment of
(1) the progress of the applicant's development as an independent clinical or basic science investigator and (2) the institutional
value of the applicant's research.  In discussing the applicant's research accomplishments, please compare the applicant to
others with a similar degree of training.
Attach File:
Please attach
your assessment:

no file selected

Instructions: Click the "Browse" button
and locate your file. We accept most word
processing formats.

File successfully uploaded. View it

Cancel

Save and Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 30 minutes, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information, unless is displays a currently valid OMB control number. Send comments regarding
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 2674-14
Privacy Act 09-25-0165

Please periodically click SAVE & CONTINUE in order to not lose
work in progress. You will automatically be logged off the LRP
Web site if you have not moved to a new page in any one hour
time period.