Form 8 UGSP

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UNDERGRADUATE SCHOLARSHIP PROGRAM
OMB No. 0925-0299
Expiration Date 03/31/2014
Respondent Burden
PROGRAM APPLICATION
Instructions: Before you begin, you may want to review some helpful hints on using this electronic form and our privacy statement.
Eligibility Criteria:
1. Candidates must be U.S. citizens or U.S. permanent residents.
2. Candidates must be enrolled or accepted for enrollment as a full-time student at an accredited 4-year undergraduate institution
located in the United States of America.
3. Candidates must have an Undergraduate University Grade Point Average of 3.3 or higher on a 4.0-point scale or within the top 5
percent of your class.
4. Candidates must have an 'Exceptional Financial Need' as certified by your undergraduate institution financial aid office (Federal
Register, Vol. 77, No. 74, Tuesday, April 17, 2012).
Application Tips:
This form allows you to save a partially completed application. To take advantage of this feature:
Enter as much information into the form as you would like. Note that you must complete certain fields--Name, E-mail Address,
Phone, etc. --in order to save a partial application.
Press "Save Partial Application & Quit" to save the information you have entered thus far. You will have to return later to complete
your application.
When you first submit your partial application, you will receive an e-mail message containing instructions for accessing the online
tool that allows you to review, modify, and complete your application.
Only completed applications are available for review by NIH investigators and administrators; partial applications are not accessible by
NIH investigators. 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 select the "Save" button on the Preview
page.
IMPORTANT NOTE: The deadline for receipt of completed applications is March 1, 2013 (11:59 p.m., Eastern Standard Time).
Applications that are incomplete after the March 1 deadline will not receive further consideration.
1. Please read the "Undergraduate Scholarship Program page" and ""UGSP Frequently Asked Questions" 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 appear as you intend, 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 early as possible and ensure that your references submit their letters promptly using our online

5. Complete your application as early as possible and ensure that your references submit their letters promptly using our online
system.
6. Letters of recommendation are due no later than March 15, 2013, at 11:30 pm EDT. We will not accept letters after that time.
Indicates a required field.

Indicates a help button.

1. Minimally Required
You must enter this information if you wish to save your application.
Name:

Mr.
Prefix

First

MI

Last

E-mail Address:
Permanent Home Phone:
Citizenship Status:
Current Education Level:
Year at Current Level:
Enrollment:

Format: (999) 999-9999
US Citizen
College/University (4 year)
1st
Are you enrolled in, or have you applied to, a 4-year college/university program located
in the U.S.?
Yes

No

Certification of Non-Delinquent Status: The Federal Debt Collection Procedures Act of 1990 precludes a debtor who has a Federal
judgment lien against his/her property arising from a Federal debt from receiving Federal funds until the judgment is paid in full or
otherwise satisfied. Applicants of the NIH Undergraduate Scholarship Program must certify that they do not have a judgment lien
against their property arising from a debt to the United States.

I certify I do not have delinquent status.
I agree

I disagree

Certification of Application - Information is True, Complete, and Accurate: I certify that information given in this application
(including any personal statements) is true, complete, and accurate to the best of my knowledge and does not omit any material
fact, which would render the statement false, fictitious, or fraudulent as a result of the omission. I understand that the information
given may be investigated and that any false representation is sufficient cause for rejection of this application, or, if awarded
scholarship benefits, that I am liable for return of all awarded funds and, further, that any false statement may be punishable as a
felony under U.S. Code, Title 18, Section 1001. I am aware that any false, fraudulent, or fictitious statement may, in addition to other
remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986.
I agree

I disagree

Certification of Application - Release of Information to UGSP: To ensure your eligibility requirements, the UGSP may need to
contact your academic institutions for clarification of information in your application or financial form.

I authorize the program(s) indicated in my Educational History to release information about my academic, financial, service, and any
other pertinent information to administrators of the NIH Undergraduate Scholarship Program (UGSP) and to other authorized
Government officials. This release is valid for six months after completion of all UGSP requirements.
I agree

2. Personal Information
Permanent Address:

City:
State:

I disagree

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

United States

3. Academic Information
Do you have coursework from a 2-year academic institution?
Yes

No

Are you, or do you anticipate, transferring from a 2-year program to a 4-year program in Fall 2013?
Yes

No

College or University
This section is required if you are a student at a 4-year college/university.
College/University Name:
Start Date:
Anticipated Graduation Date:
Major Field of Study:
Current Cumulative GPA:
GPA Scale (Maximum Value):
College or University
Coursework and Grades:

Community College
This section is required if you indicated above that you have coursework from a 2-year institution.
Community College Name:
Start Date:
Anticipated Graduation Date:
Major Field of Study:
Current Cumulative GPA:
GPA Scale (Maximum Value):
Community College
Coursework and Grades:

High School
This section is required if you are a 1st-year student.

High School
Coursework and Grades:

4. CV/Resume Sections
Copy and paste a plain text version of your curriculum vitae or resume into the sections below. Some reformatting may be necessary.
Personal Statement: (Up to 9000 characters)

Scientific Discipline / Research Interests: (Up to 600 characters)

Describe how a person or an event has influenced your career choice: (Up to 3000 characters)

Career Interests: (Up to 3000 characters)

Awards & Honors: (Up to 3000 characters)

Experiences & Activities: (Up to 6000 characters)

Additional Information: (Up to 1500 characters)

5. References
Under the Family Educational Rights and Privacy Act of 1974, as amended (P.L. 93-380), you have the right to access the information

Under the Family Educational Rights and Privacy Act of 1974, as amended (P.L. 93-380), you have the right to access the information
contained within a letter of recommendation unless you have waived such access. The National Institutes of Health (NIH) does not
require you to waive your permission as a condition of admission. For each reference, your response about waiving access to each
letter of recommendation is required. Your references will be given your response in the recommendation request message sent by
email. See Family Educational Rights & Privacy Act.
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:
Mr.

Name:

Prefix

First

Last

E-mail:

Format: [email protected]

Waive Access:

Yes

No

Reference 2:
Mr.

Name:

Prefix

First

Last

E-mail:

Format: [email protected]

Waive Access:

Yes

No

Reference 3:
Mr.

Name:

Prefix

First

E-mail:
Waive Access:

Format: [email protected]
Yes

No

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:

Last

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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Preview Completed Application

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UNDERGRADUATE SCHOLARSHIP PROGRAM
LETTER OF RECOMMENDATION FOR MR. FIRSTNAME LASTNAME
OMB No. 0925-0299
Expiration Date 3/31/2014
Respondent Burden
Instructions:
Please complete the form and click on the button below to submit your evaluation and letter of reference.
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.
Indicates a required field.
Evaluation Form
How long have you known the applicant?

Length:

In what capacity have you known the applicant?

Capacity:

The evaluation form asks for your assessment on several aspects using the following rating system.
5 = Exceptional - Top 1%
4 = Excellent - Top 10%
3 = Above Average - Top 25%
2 = Average - Top 50%
1 = Below Average - Bottom 50%
Note: Mr. Firstname Lastname has waived access to view your letter of recommendation.
Overall Impression:
5

4

3

2

1

Intelligence:
5

4

Writing Ability:
3

2

1

2

1

Analytical Ability:
5

4

3

4

3

4

3

Service Obligation:

3

2

1

5

4

3

2

2

1

5

4

1

5

4

4

3

2

1

5

4

3

2

1

Knowledge of Field:
3

2

1

Confidence:
2

5

Honesty:
1

Motivation:

Verbal Ability:
5

4

Interpersonal Skills:

Research Ability:
5

5

Initiative:

5

4

3

2

1

3

2

1

Maturity:
3

2

1

5

4

Service Obligation:
Indicate the likelihood of the applicant completing the service obligation asscoiated with the UGSP scholarship.
5

4

3

2

1

Recommendation Letter
Please copy and paste your letter of reference into the boxed area below. 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

3/6/13 3:03 PM

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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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