Form 1 LRP Ambassador Sign-up Form

Form Approved

OMB Number 0925-0740

Expiration Date 05/2019

Sign-up Form for Ambassadors

I am willing to serve as an LRP Ambassador. I understand that my responsibilities as an LRP Ambassador are to:

1. Learn about the LRPs and the application process in order to be an informed communicator.

2. Identify potential eligible applicants to the LRPs within their institutions.

3. Share relevant information about the LRPs to these potential applicants in a timely manner through face-to-face encounters, electronic communication, and planned events.

4. Share/report information on their activities with NIH/DLR staff.

Name: ______________________________________________

Institution: ___________________________________________

Address: _____________________________________________

_____________________________________________________

Telephone: ___________________________________________

Email: _______________________________________________

Year Received LRP: _____________________________________

Type of LRP: ___ Clinical Research ____ Pediatric Research ____ Health Disparities Research

____ Clinical Research for Disadvantaged Individuals ____Infertility and Contraception

Primary Research Interest: ___________________________________________

I do hereby grant or deny permission to the National Institutes of Health (NIH) Loan Repayment Programs (LRP) to use my name, contact details, biography, image and professional details, as indicated below. Such use includes the display, distribution, publication, transmission, or otherwise use of my personal details in materials that include, but may not be limited to, NIH’s LRP website, as well as printed materials such as brochures and newsletters, videos and digital images.

Choose one of the following:

_____ Grant permission to publish my name, institution, telephone number, and email address on the LRP website as part of a directory of LRP Ambassadors.

______ Grant permission to share my name, contact information, biography, image, and professional details on the LRP website and in other materials, e.g., in “success stories” about LRP awardees.

______ Deny permission to NIH’s LRP to share my personal information in any way.

______ Check here to indicate that you have read and agree to the terms of the Sign-up Form for Ambassadors.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, 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 it 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, ATTN: PRA (0925-0648).  Do not return the completed form to this address.