Form 1 EDI Demographic Form of Applicants to NIH Training and F

OMB No.: 0925-0740

Expiration Date: 5/2019

DEMOGRAPHIC SURVEY FOR APPLICANTS TO NIH TRAINING AND FELLOWSHIP PROGRAMS

Training Program:

YOUR PRIVACY IS PROTECTED

This information is collected and used to determine whether the National Institutes of Health (NIH) is reaching a diverse population of applicants for its training and fellowship programs. Your individual responses will be kept secured to the extent permitted by law. The information collected will only be disclosed in aggregate as NIH evaluates its efforts to reach a diverse population of applicants. Completion of this form is voluntary. No individual selections are made based on this information, and selecting officials will not have access to individual responses. There will be no impact on your application if you choose not to answer any of these questions.

Public reporting burden for this collection of information is estimated to average five 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.

1. Sex (Check One):

   • Male

   • Female

2. Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

 Yes

 No

Please select the racial category or categories with which you most closely identify by placing an “X” in the appropriate box. Check as many as apply.
RACIAL CATEGORY (Check as many as apply)	DEFINITION OF CATEGORY
 American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White	A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. A person having origins in any of the black racial groups of Africa. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

4. The next questions address disability and serious health conditions. Your responses will ensure that our outreach and recruitment policies are reaching a wide range of individuals with physical or mental conditions. Consider your answers without the use of medication and aids (except eyeglasses) or the help of another person.

1. Do you have any of the following? Check all boxes that apply to you:

Targeted Disabilities or Serious Health Conditions:

• 02- Developmental Disability, for example, autism spectrum disorder

• 03- Traumatic Brain Injury

• 19- Deaf or serious difficulty hearing, benefiting from, for example, American Sign Language, CART, hearing aids, a cochlear implant and/or other supports

• 20- Blind or serious difficulty seeing even when wearing glasses

• 31- Missing extremities (arm, leg, hand and/or foot)

• 40- Significant mobility impairment, benefiting from the utilization of a wheelchair, scooter, walker, leg brace(s) and/or other supports

• 60- Partial or complete paralysis (any cause)

• 82- Epilepsy or other seizure disorders

• 90- Intellectual disability

• 91- Significant Psychiatric Disorder, for example, bipolar disorder, schizophrenia, PTSD, or major depression

• 92- Dwarfism

• 93- Significant disfigurement, for example, disfigurements caused by burns, wounds, accidents, or congenital disorders

Other Disabilities or Serious Health Conditions:

• 13- Speech impairment

• 41- Spinal abnormalities, for example, spina bifida or scoliosis

• 44- Non-paralytic orthopedic impairments, for example, chronic pain, stiffness, weakness in bones or joints, some loss of ability to use part or parts of the body

• 51- HIV Positive/AIDS

• 52- Morbid obesity

• 59- Nervous system disorder for example, migraine headaches, Parkinson’s disease, or multiple sclerosis

• 80- Cardiovascular or heart disease

• 81 – Depression, anxiety disorder, or other psychiatric disorder

• 83- Blood diseases, for example, sickle cell anemia, hemophilia

• 84- Diabetes

• 85- Orthopedic impairments or osteo-arthritis

• 86- Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema

• 87- Kidney dysfunction

• 88- Cancer (Present or past history)

• 94- Learning disability or attention deficit/hyperactivity disorder (ADD/ADHD)

• 95- Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome, colitis, celiac disease, dysphexia

• 96- Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis

• 97- Liver disease, for example, hepatitis or cirrhosis

• 98- History of alcoholism or history of drug addiction (but not currently using illegal drugs)

• 99- Endocrine disorder, for example, thyroid dysfunction

2. If you did not select one of the options above, please indicate whether.

• 01 - I do not wish to identify my disability or serious health condition.

• 05 - I do not have a disability or serious health condition.

• 06 - I have a disability or serious health condition, but it is not listed on this form.

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