Form 4040-0001 Research and Related Personal Data

OMB Approval No.:4040-0001
Expiration Date: mm/dd/yyyy

RESEARCH & RELATED PERSONAL DATA

Project Director/Principal Investigator and Co-Project Director{s)/Co-Principal lnvestigator(s)
The Federal Govemmenl has a continuing commitment to monitor the operation of its review and award processes to identify and address any Inequities
based on gender, race. ethnicijy, or disability of its proposed PDs/Pls and co-PDs/Pls. To gather information needed for this important task, the
applicant should submit the requested information for each identified PD/Pl and co-PDs/Pls with each proposal. Submission of the requested
information is voluntary and is not a precondition of award. However. information not submitted will seriously undermine the statistical validity, and
therefore the usefulness, of information received from others. Arly individual not wishing to submit some or all the information should check the box
provided for this purpose. Upon receipt of the application. this form will be separated from the application. This form will not be duplicated, and it will not
be a part of the review process. Data will be confidential.
Project Director/Principal Investigator
Profix:

• First Name:

Middle Name:

• Last Name:

Suffix:

Gender:
Race (check all that apply):

Ethnicity:

Disability Status (check all that apply):

0American Indian or Alaska Native

0Hearing

0Asian

Ovisual

0Black or African American

0 Mobility/Orthopedic Impairment

D Native Hawaiian or Other Pacific Islander

Oother

0White

0None

0 Do Not Wish to Provide

0 Do Not Wish to Provide

Citizenship:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 4040-0001. The time required to complete this information collection is estimated to average 1 hour per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200
Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer