26 Academy Fellows&Certificate Application

NIH ACADEMY FELLOWS & NIH ACADEMY CERTIFICATE PROGRAM ‐ APPLICATION
OMB Clearance Number: 0925-0299
Expiration Date: 30-Jun-2019

Indicate your current status:*

First Name (Given Name):*

Last Name (Family Name):*

NIH or University E‑mail Address:*

Permanent E‑mail Address:*

Institute‑Center:

Which NIH Campus will you be performing your post‑baccalaureate research training?:

What is your projected arrival date?:

Program of Interest:*

Letter of Interest:*

Discuss a health disparities topic of interest to you. Why is it important and what is
currently being done to address this disparity?:*

Describe a time when you had to be resilient.*

Submit Survey

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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 15 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 0MB 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.