Form 1 ODS DSRP application 2021 registration

Dietary Supplement Research Practicum: Application

OMB#: 0925-0740 Exp Date: 07/2022 Application The application deadline is XXXday, Month XX, 2021, at 5 p.m. Eastern Time. 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 (0925-0740). Do not return the completed form to this address. The Mary Frances Picciano Dietary Supplement Research Practicum will be held virtually on May 26-28, 2021. Below you will find an application form for the practicum. Please fill out the following fields, which request contact information and descriptions of your background. There is no way of saving your application in progress, so you may want to compose your responses in a word processing program and plan to fill out the application and submit it in a single session. You may wish to review the Application & Selection criteria for information about our admission criteria before preparing your application. If you have any questions about applying, please send an email to [email protected]. Please note: All fields are required unless otherwise noted.
Contact Information
Salutation (optional)
First Name
Last Name
Suffix (optional)
Title or position	Click or tap here to enter text.
	For example, Assistant Professor, Postdoctoral Research Associate, Registered Dietitian
Mailing Address 1
Mailing Address 2
Mailing Address 3
City
State or Province	(Required for U.S., Canada, Australia)
ZIP/Postal Code
Country
Phone Number	If you reside in the U.S., please include your area code with the telephone number, for example 301–555–5555. If you reside outside the U.S., please include your country code.  Ext.
Affiliation (Institution/Company)
Email
Confirm Email	(Please re-type your email address here)
How did you hear about the practicum? (optional)
Experience/Background
Please select the button that best describes your experience or employment status. You must be able to attend the entire practicum. Please do not apply if you cannot commit to participating for the entire two and a half days if accepted. Please check all that apply.
I am a full-time assistant, associate, or full professor.  I am a doctoral student, postdoc, or a fellow (as of September 2020).  I am master’s degree student in a recognized academic program or am attending medical, dental, or nursing school or a related non-doctoral-level professional program.  I am a practicing health professional with at least a master’s degree from a recognized academic program who works in either a healthcare, educational, or industrial setting or is self-employed.  I am a part-time or adjunct faculty member at a recognized academic institution.  I have attended the practicum before.
Curriculum Vitae/Resume
Please provide a copy of your CV or resume in PDF format.