22 Attachment 7E PHS 416-1 Face Page 4

PHS Applications and Pre-award Related Reporting (OD)

Attachment 7E PHS 416-1 Face Page 4

416-1

OMB: 0925-0001

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KirschsteinNRSA Individual Fellowship Application

Table of Contents

NAME OF APPLICANT (Last, first, middle initial)

     

Section I — Applicant/Fellow

Page Numbers

(Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 6a, 6b.)

Face Page

1


Sponsor’s Contact Information, Description (Form Page 2)

2


Training & Career Goals, Activities Planned Under This Award, Training Site(s),
Human Embryonic Stem Cells (Form Page 3)

3


Table of Contents (Form Page 4)

     


Biographical Sketch – Applicant/Fellow (Not to exceed five pages)

     


Previous Research Experience (Form Page 5)

     


Research Training Plan



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1. Introduction to Resubmission Application (not to exceed 1 page)

     


2. Specific Aims

     


3. Background/Significance (Items 2-5 not to exceed 10 pages)

     


4. Preliminary Studies/Progress Report ………………………………………………………….

     


5. Research Design and Methods

     


6. Inclusion Enrollment Report (for Renewal applications only)

     


7. Progress Report Publication List (for Renewal applications only)

     


8. Human Subjects (Required if Item 9 on the Face Page is marked “Yes”)

     


9. Clinical Trial

     


10. Agency-Defined Phase III Clinical Trial

     


11. Protection of Human Subjects (Required if Item 9 on the Face Page is marked “Yes”)

     


12. Inclusion of Women and Minorities (Required if Item 9 on the Face Page is marked “Yes”
and is Clinical Research)

     


13. Targeted/Planned Enrollment Table (for new and continuing clinical research studies)

     


14. Inclusion of Children (Required if Item 9 on the Face Page is marked “Yes”)

     


15. Vertebrate Animals (Required if Item 10 on the Face Page is marked “Yes”)

     


16. Select Agent Research

     


17. Bibliography and References Cited (formerly “Literature Cited”)

     


18. Resource Sharing

     


19. Respective Contributions

     


20. Selection of Sponsor and Institution

     


21. Responsible Conduct of Research

     


Section II — Sponsor’s/Co-Sponsor’s Information



Biographical Sketch--Sponsor

     


Research Support Available

     


Previous Fellows/Trainees

     


Training Plan, Environment, Research Facilities

     


Number of Fellows/Trainees to be Supervised

     


Applicant’s Qualifications and Potential

     


Checklist (Completed by Fellow/Applicant & Sponsoring Institution)

     


Section III — Letters of Reference (Minimum of 3)

(See instructions for submission of references.)

List full name, institution, and department of individuals submitting reference letters.

     

Other Items (list):

Personal Data Page for Fellowship Applicants

     

Appendix

Appendix (five identical CDs)

Check if

Appendix is

Included

PHS 416-1 (Rev. 6/15) Page 4 Form Page 4

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePHS 416-1fp4 (Rev. 8/12), Table of Contents, Form Page 4
SubjectRuth L. Kirschstein National Research Service Award Individual Fellowship Application
AuthorDHHS, Public Health Service
File Modified0000-00-00
File Created2021-01-14

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