Form 2 Form-- Mentor Information and Agreement

OMB #0925-0733

Expiration date 02/28/2019

Public reporting burden for this collection of information is estimated to take 20 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 20902-7974, ATTN:PRA (0925-0733). Do not return the completed form to this address.

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 into the Application.

Applicant First Name:      

Applicant Last Name:      

Applicant Email:      

Mentor Full Information

1. First/Given Name of Mentor:

     

2. Last/Family Name of Mentor:

     

3. Position Title:

     

4. Institution:

     

5. Department, Division, Service, Laboratory:

     

6. Office Mailing Address (street address, city, state, postal code):

     

7. Country:

     

8. Office Phone (country code, city code, number):

     

9. Primary E-mail:

     

10. Alternative E-mail:

     

Education

Education

1) Name and Location of Institution:      

Degree:      

Degree Completed (MM/YYY):      

Field of Study:      

2) Name and Location of Institution:      

Degree:      

Degree Completed (MM/YYY):      

Field of Study:      

3) Name and Location of Institution:      

Degree:      

Degree Completed (MM/YYY):      

Field of Study:      

4) Name and Location of Institution:      

Degree:      

Degree Completed (MM/YYY):      

Field of Study:      

List up to 10 of your most significant publications, honors, awards, or other accomplishments , including current membership on a federal government public advisory committee..

     

In addition to the applicant, how many predoctoral and postdoctoral fellows/trainees will be supervised during the fellowship period?      

List the total number of pre- and postdoctoral fellows have you trained?      

List up to five of the most recent pre- and postdoctoral fellows you have trained, (e.g. name, current employer, position title).

     

Mentor’s Statement

Mentors must submit a statement not to exceed three pages. Only PDF or MS Word formats are accepted. Your statement should include:

1. Describe the Research Plan for the applicant. Include such items as seminars and opportunities for interaction with other groups and scientists. Describe the research environment and available research facilities and equipment. Include information that will help reviewers evaluate the applicant and the proposed research project. Indicate the relationship of the proposed research to the applicant’s career. Describe the skills and techniques that the applicant will learn and relate these to the applicant’s career goals.

2. Describe the applicant’s qualifications and potential for a research career.

3. Please assess the feasibility of the Research Plan with respect to current NIH regulations on the conduct of research.

4. Please describe the applicant’s understanding of the U.S. federal guidelines regarding the conduct of research, and how will you ensure that the applicant complies with all NIH and institutional regulations.

Important Note: If you make any changes to your mentor statement 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 statement was SamSmithMentorStatement, the file name for the revised document should be SamSmithMentorStatement2.

Upload your mentor statement. Only PDF or MS Word formats are accepted.      

Mentor Certification and Acceptance

By checking the box, I,      , declare that I have read and understandd the U.S. Ffederal 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.