Form 25 PBT Recommendation Letters

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POSTBACCALAUREATE IRTA PROGRAM
LETTER OF RECOMMENDATION FOR FORENAME SURNAME
OMB Clearance Number: 0925-0299
Expiration Date 30-June-2019
Instructions:

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Reference Letter
If applicable, please update the fields below so that they correctly reflect your title, name, and phone number.
Name:

Dr.
Title

First Name

MI

Last Name

Phone:

Reference Letter
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signature block.

Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights of participants are protected by
The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. The
information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of
the study. Information provided will be combined for all participants and reported as summaries.
Public reporting burden for this collection of information is estimated to average 10 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 (0925-0299). Do not return the completed form to this address.