Form 1 Application

OMB #0925-0733

Expiration date 02/28/2019

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International Research Fellowship Award Program Application

Post-Doctoral Applicant (English Language Only)

This revised application submitted for OMB review reflects the current web-based application and program requirements, including expanding the research topics to be investigated, limiting mentors to NIH/NIDA grantees at U.S. institutions, and incorporating the assurance of ethical research conduct.

Applicant Information

1. First/Given Name of Applicant:

     

2. Last/Family Name of Applicant:

     

3. Country of Citizenship (if dual citizenship, list both):

     

4. Year of Birth (yyyy):

     

5. Sex or Gender:

     

6. Advanced Degree(s):

     

7. Position Title:

     

8. Name of Institution:

     

9. Department, Division, Service, Laboratory:

     

10. Institution Mailing Address (street address, city, state, postal code):

     

11. Country:

     

12. Phone (country code, city code, number):

     

     

13. Primary E-mail:

     

14. Permanent Home Address (street address, city, country, postal code):

     

     

15. Alternative E-mail:

     

Applicant’s References

Colleague/Supervisor 1 Name (Last/Family, First/Given):      

Email:      

Colleague/Supervisor 2 Name (Last/Family, First/Given):      

Email:      

Mentor

Name of Mentor (First/Given Name and Last/Family Name)      

Name of Mentor’s Institution      

Institution Mailing Address (including city and country)      

Phone      

Mentor’s Primary Email Address      

Applicant’s Personal History

Education—List all postsecondary institutions you attended, beginning with the most recent.

1) Name and Location of Institution:      

Major Field(s) of Study:      

Begin and End Dates of Attendance (Month, Year to Month, Year):       to      

Name of Diploma or Degree:      

Title(s) of Theses/Dissertations (if any):      

2) Name and Location of Institution:      

Major Field(s) of Study:      

Begin and End Dates of Attendance (Month, Year to Month, Year):       to      

Name of Diploma or Degree:      

Title(s) of Theses/Dissertations (if any):      

3) Name and Location of Institution:      

Major Field(s) of Study:      

Begin and End Dates of Attendance (Month, Year to Month, Year):       to      

Name of Diploma or Degree:      

Title(s) of Theses/Dissertations (if any):      

4) Name and Location of Institution:      

Major Field(s) of Study:      

Begin and End Dates of Attendance (Month, Year to Month, Year):       to      

Name of Diploma or Degree:      

Title(s) of Theses/Dissertations (if any):      

Applicant’s Personal History (continued)

Additional Training ; (include U.S. National Institutes of Health sponsored activities or funding)

1) Activity/Event:      

Field:      

Institution:      

Begin and End Dates of Attendance (Month, Year to Month, Year):       to      

2) Activity/Event:      

Field:      

Institution:      

Begin and End Dates of Attendance (Month, Year to Month, Year):       to      

3) Activity/Event:      

Field:      

Institution:      

Begin and End Dates of Attendance (Month, Year to Month, Year):       to      

4) Activity/Event:      

Field:      

Institution:      

Begin and End Dates of Attendance (Month, Year to Month, Year):       to      

List your 5 to 10 most recent peer-reviewed publications.

     

List your significant honors, awards, projects, or other accomplishments.

     

List Your Current Employment.

Name Current Employer:      

Address, City and Country of Current Employer:      

Current Job Title:      

Begin Date of Employment (Month, Year):      

End Date of Employment (Month, Year) if applicable:      

Describe your current job responsibilities:      

Previous Employment.

1) Employer/Hosting Institution:      

Job/Position Title:      

Begin and End Date(s) (Month, Year to Month, Year):       to      

2) Employer/Hosting Institution:      

Job/Position Title:      

Begin and End Date(s) (Month, Year to Month, Year):       to      

3) Employer/Hosting Institution:      

Job/Position Title:      

Begin and End Date(s) (Month, Year to Month, Year):       to      

4) Employer/Hosting Institution:      

Job/Position Title:      

Begin and End Date(s) (Month, Year to Month, Year):       to      

Applicant’s Research Proposal

Fellowship Goals

Provide a summary of your goals for the fellowship (limit 500 characters).

     

Research Proposal Abstract—Limit your abstract to 2000 characters.

Explain the research opportunities the institution and mentor offer that are not currently available in your home country. Describe key factors in your selection of your mentor (limit to 1,000 characters).

     

Applicant’s Research Proposal (continued)

Applicant’s Full Research Plan.

Applicants must submit a complete research plan. Your plan may not exceed three pages, not including literature citations. Your plan should include:

1. Specific aims

2. Background and significance

3. Research design and methods

4. A statement of assurance that research presented in this application will be conducted in compliance with National Institutes of Health (NIH) regulations on the conduct of research.

5. Literature citations (each citation must include the authors’ names, book or journal title, volume number, page numbers, and year of publication).

Important Note: If you make any changes to your research plan and need to upload a new version, you must use a different name for the revised file. For example, if the file name for your first plan was SamSmithResearchPlan, the file name for the revised document should be SamSmithResearchPlan2.

Upload your research plan. Only PDF or MS Word formats are accepted.      

Applicant Certification and Acceptance

By checking the box, I,      , declare that I have read and understand the U.S. Federal regulations on the conduct of research supported by the National Institutes of Health (NIH). I certify that the statements herein are true, complete, and accurate to the best of my knowledge, and I accept the obligation to comply with terms and conditions if a fellowship is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

An incomplete certification and acceptance section will disqualify your fellowship application.