Form 3 PBTP

NIH Office of Intramural Training & Education - Online Application

2/8/13 1:50 PM

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POSTBACCALAUREATE/TECHNICAL IRTA PROGRAM
PROGRAM APPLICATION
OMB No. 0925-0299
Expiration Date 03/31/2014
Respondent Burden

Before you begin, watch a new video: Applying to the NIH Postbac Program.
Instructions:
Before you begin, you may want to review some helpful hints on using this electronic form and our privacy statement.
This form allows you to save a partially completed application. To take advantage of this feature, please proceed as follows:
Complete the first section of the form and enter as much additional information into the form as you would like.
Press "Save Partial Application & Quit" to save the information you have entered thus far, and return later to complete your
application.
When you first submit your partial application, you will automatically receive a confirmation e-mail containing login information
and instructions for accessing the online tool that allows you to review, modify, and complete your application.
Once you complete your application, press "Preview Completed Application." You will be taken to a page displaying the information
you have provided. To submit your completed application, you must then click the "Save" button on the Preview page.
IMPORTANT NOTE: NIH investigators and administrators can access completed applications only; they cannot review partial
applications.

Tips for Applying Successfully:
1. If you are applying to the Postbac IRTA program, review the Postbac IRTA program description and the associated "Frequently
Asked Questions" before beginning your online application. If you are applying to the Technical IRTA Program, review the
Technical IRTA program description and "Frequently Asked Questions" for that program before beginning your online application.
2. Be sure that the e-mail addresses you provide for your references are accurate. Incorrect e-mail addresses will delay the
processing of your application and could result in your application's not receiving full consideration.
3. Please note that this form accepts plain text inputs only. This means that special characters and formatting such as bullets,
"smart quotes," bold or italic fonts, Greek letters, etc., will be lost or altered. To ensure your data appears as you intend it to,
compose your inputs to the longer fields on this form using a plain text editor (e.g., Notepad, for PC users, or TextEdit, for Mac
users). In place of special formatting, you will need to rely on the use of capital letters, white space, asterisks, and other standard
keyboard characters.
4. Proofread your application thoroughly for accuracy and completeness; false or inaccurate information may be grounds for denying
your candidacy or removing you from the program.
5. Complete your application as soon as possible and encourage your references to submit their letters promptly using our online
https://www2.training.nih.gov/apps/publicForms/pbt/forms/pbtApp.aspx?appType=P

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NIH Office of Intramural Training & Education - Online Application

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system.
6. NOTE: There is no deadline for applying to either the Postbac IRTA program or the Technical IRTA program; applications are
accepted on a rolling basis.
Eligibility Criteria:
1. All candidates must be U.S. citizens or permanent residents.
2. Candidates for the Postbac IRTA Program must have received their bachelor's degree no more than 2 years prior to the date they
begin the program. They must also intend to apply to graduate or professional (medical, dental, pharmacy, nursing) school during
the program. The general expectation is that applicants will have received their bachelor's degrees from accredited colleges or
universities in the U.S.; however, U.S. citizens whose degrees are from other nations may apply for a waiver of this requirement.
Permanent residents must have received their bachelor's degrees from U.S. institutions to be eligible to participate.
3. Candidates for the Technical IRTA program must have graduated from a fully accredited U.S. college or university with a bachelor's
or master's degree.
Indicates a required field!

1. Personal Information
You must enter this information if you wish to save your application.

Training Program:

Name:

Postbaccalaureate IRTA

Technical IRTA

Mr.
Prefix

Month/Day of Birth:

First

/

MI

Last

(mm/dd)
Format: [email protected]

E-mail Address:
To obtain a free e-mail address, click here
Preferred Phone Number:

Citizenship Status:

Format: (999) 999-9999

US Citizen

Month and Year Bachelor's
Degree Received/Expected:
Bachelor's Degree is from an
Accredited U.S. Institution?
Master's Degree Earned?

/

(mm/yyyy)

Yes

No

Yes

No

Master's Degree Received/Expected
(if applicable):
Master's Degree is from an

/
Yes

(mm/yyyy)
No

Not Applicable

Accredited U.S. Institution?

Personal Information - Continued
Permanent Address:

https://www2.training.nih.gov/apps/publicForms/pbt/forms/pbtApp.aspx?appType=P

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City:
State:
(Use DC for District of Columbia and NA if your permanent address is not in the U.S.)
Zip Code:
Country/Region:

United States

Permanent Home Phone:
Relative at NIH/FDA:

Format: (999) 999-9999
Yes

No

Help: Definition of "relative"

If yes, enter the Name and Institute/Center of each Relative (please list all):

2. Academic Information
Bachelor's Institution:
Bachelor's Degree Cumulative GPA:
Bachelor's Degree Institution Grading Scale:
Note: If you select 'Other', please explain in Section 3, Coursework and Grades.
Be sure to describe your school's grading scale and your current cumulative
average relative to that scale.
Undergraduate Academic Major:

or

Bachelor's Degree Type:

Master's Institution (if applicable):
Master's Degree Cumulative GPA
(if applicable):
Master's Degree Institution Grading Scale
(if applicable):
Master's Degree Type (if applicable):

Education Plans:

or
Note: Please indicate the degree you plan to pursue after completing your time
at NIH.

3. Coursework and Grades
Please enter all the courses you have completed, not just your science courses, Also enter any courses you are currently taking or in
which you will enroll during your final semester. As you receive grades for these courses, add them here using the Modify
Application tool.
Course Title

Grade

https://www2.training.nih.gov/apps/publicForms/pbt/forms/pbtApp.aspx?appType=P

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NIH Office of Intramural Training & Education - Online Application

Course Title

2/8/13 1:50 PM

Grade

4. CV/Resume
Copy and paste a plain text version of your curriculum vitae into this space. Minor reformatting may be necessary. Include education,
relevant research experience, scientific publications, honors and awards, etc.

5. References
Once you submit your completed application, an e-mail request for a letter of recommendation will automatically be sent to
each of the following individuals:
Reference 1:
Name:

Mr.
Prefix

First

MI

Last

Address:
Phone:
E-mail:

Format: [email protected]

Reference 2:
Name:

Mr.
Prefix

First

MI

Last

Address:
Phone:
https://www2.training.nih.gov/apps/publicForms/pbt/forms/pbtApp.aspx?appType=P

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NIH Office of Intramural Training & Education - Online Application

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E-mail:

Format: [email protected]

Reference 3:
Mr.

Name:

Prefix

First

MI

Last

Address:
Phone:
E-mail:

Format: [email protected]

6. Research Interests
6a. Areas of Scientific Interest:
1.
2.
3.

6b. Medical Entity/Disease:
1.
2.
3.

7. Cover Letter:
Please write a cover letter outlining your research interests, career goals, and reasons for applying for training at the NIH.

Training Locations
Training occurs on several sites including the main campus in Bethesda, MD. To help our investigators, please indicate ALL
locations where you would be willing to train.
Bethesda, MD (main NIH campus)
Frederick, MD (some NCI labs)
https://www2.training.nih.gov/apps/publicForms/pbt/forms/pbtApp.aspx?appType=P

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NIH Office of Intramural Training & Education - Online Application

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Frederick, MD (some NCI labs)
Baltimore, MD (most NIA labs and all NIDA labs)
Research Triangle Park (Raleigh/Durham), NC (NIEHS only)
Hamilton, MT (limited positions in NIAID)
Phoenix, AZ (limited positions in NIDDK)
Detroit, MI (limited positions in NICHD)
Framingham, MA (limited positions at NHLBI)

How did you hear about this program? (Please select all that apply.)
Ad in a scientific journal (Nature, Science); please specify:
Ad in a student journal; please specify:
Ad in a meeting program
Exhibit at a meeting; please specify:
Career development/opportunities workshop
Flier
Poster
From a mentor or advisor
From an alumnus/alumna of the program
NIH representative visited school
Web search
Other; please specify:

Notice to all applicants:
It is your responsibility to ensure that all of the above information is correct. False or inaccurate information contained in this
application may be grounds for denying your candidacy or removing you from the program.
Save Partial Application & Quit

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POSTBACCALAUREATE IRTA PROGRAM
LETTER OF RECOMMENDATION FOR MR. TEST-PATRICIA TEST-WAGNER
OMB No. 0925-0299
Expiration Date 3/31/2014
Respondent Burden
Instructions:
Copy and paste your letter of reference into the boxed area below. (Note: We recommend that you compose your letter off-line
and paste it into the space below. If you attempt to compose your letter while logged on to this site, you may experience a
connection timeout or some other technical problem beyond our control, which may result in your text being irretrievably lost.)
Click on the button below to submit your letter.

Reference Letter
Please update the fields below so that they correctly reflect your name, phone number and address.
Name:

Mr.
Title

REF2-Firstname
First Name

Address:

REF2-Address

Phone:

(222) 222-2222

REF2-Lastname
MI

Last Name

Reference Letter
Please include your name, academic rank, department and institution in your signature block.

Submit

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Respondent Burden

3/6/13 3:02 PM

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RESPONDENT BURDEN
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Statement for Applicants/Registrants
Public reporting burden for this collection of information is estimated to average 60-minutes per submission, including the time for
reviewing instructions, frequently asked questions, and entering data in the form fields. 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 0925-0299. Do not
return the completed form to this address.

Statement for References
Public reporting burden for this collection of information is estimated to average 15-minutes per response, including the time for
reviewing instructions. 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 (0925-0299). Do not return the completed form to this address.

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Privacy Statement

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PRIVACY ACT NOTIFICATION STATEMENT
MESSAGE
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The primary use of information collected via the Office of Intramural Training and Education (OITE) online forms is to evaluate an
applicant's qualifications for research training at the National Institutes of Health (NIH). Information may be used during admission
consideration; in preparing appointment paperwork; and to provide data for training program evaluation. Information will be disclosed
to investigators, members of advisory committees, OITE staff, and contractors working on our behalf. Additional disclosures may be
made to law enforcement agencies concerning violations of law or regulation. Application for this program is voluntary; however, in
order for the OITE to process an application, the applicant must complete the required fields.
The legal authority granted to NIH to train future biomedical scientists comes from several sources. Title 42 of the U.S. Code, Sections
241 and 282(b)(13) authorize the Director, NIH, to conduct and support research training for which fellowship support is not provided
under Part 487 of the Public Health Service (PHS) Act (i.e., National Research Service Awards), and that is not residency training of
physicians or other health professionals. Sections 405(b)(1)(C) of the PHS Act and 42 U.S.C. Sections 284(b)(1)(C) and 285-287 grant this
same authority to the Director of each of the Institutes/Centers at NIH.
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