Form 1 HDRI Application 2017

OMB Number: 0925-0740

Expiration Date: May 2019

Health Disparities Research Institute (HDRI)

Application are due by May 12, 2017 (11:59pm EST).

Public reporting burden for this collection of information is estimated to average 25 minutes per submission. 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 0925-0740. Do not return the completed form to this address.

Please complete application below. Fields marked with an asterisk (*) are mandatory. Incomplete applications will not be considered. Previous participants of the HDRI or the Translational Health Disparities Course are not eligible to apply.

APPLICANT INFORMATION

   

Name

* Last	* First	MI

Gender

   M   F

Race

American Indian or Alaska Native
Asian
Black or African American

Native Hawaiian or Other Pacific Islander

White

More than One Race

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Date of birth

Day___ Month____ Year_____

 

Degrees/Credentials

 

Professional Title

 

* Organization /Academic Institution

 

Department / Division

   

* Mailing Address

Street	City	State	Zip Code

 

* Daytime Phone
(xxx-xxx-xxxx):

Secondary Email (optional)

Please provide a secondary email address.

 

* Please identify your affiliation:

 Academic Institution

 Community-based Organization/Non-profit

 Public Sector (state, local)

Private/Industry Sector

NIH BIOSKETCH

Upload your NIH Biosketch

BUTTON Here

ESSAY QUESTION

 

* Please discuss your interest in the Health Disparities Research Institute and how it will contribute to your work/future career goals in the area of minority health and health disparities.

(350-word limit, copy and paste)

 

 

RESEARCH PROJECT ABSTRACT

 

* Please submit a research abstract that describes a research project that you would like to undertake. Your abstract should include specific aims, research hypothesis, research approach, and significance to addressing minority health and/or health disparities.

(850-word limit, copy and paste)

 

 

REFERENCES

 

* Please provide the following information on the persons who will serve as your references. References need to be on letterhead and in PDF format for uploading (2-page limit).

   

Name (Reference 1)

* Last	* First	MI

 

* Professional Title

 

Institution

 

* Email

* Daytime Phone
(xxx-xxx-xxxx):

Submit letter of Recommendation (BUTTON)

(PDF on letterhead, 2-page limit)

   

Name (Reference 2)

* Last	* First	MI

 

* Professional Title

 

Institution

 

* Email

Please double check your reference's email address.

* Daytime Phone
(xxx-xxx-xxxx):

Submit letter of Recommendation (BUTTON)

(PDF on letterhead, 2-page limit)

How did you learn about this Course

 NIMHD website

 NIMHD listserv

Social media (Facebook, Twitter)

Other

 

Please note that the NIMHD Health Disparities Research Institute can accommodate only a limited number of applicants. An applicant who fails to attend after acceptance denies another worthy applicant the opportunity to participate. Therefore, if accepted, you assure the NIMHD that you will participate in the Program from August 14 through August 18, 2017.

 

* I have checked this box as proof that I have read and understand that if accepted, I will participate in the full Program.

* Important: Please double check the email addresses of your references before submitting.

For more information, please contact: [email protected]

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