Form 1 CCIS Awards Program Submission Form

Submission Form
OMB No. 0925-0766
Expiration Date: 04/30/2023
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Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0766). Do not return the
completed form to this address.

Deadline for submissions is Thursday, September 2, 2021. An asterisk (*) indicates required information.
First Name*

Last Name*

Title*

Institution*

Doctoral degrees (PhD, ScD, MD, DrPH, PharmD, MBBS, DNSc, etc.)*

Address*

City*

State/Province/Region*

Zip/Postal Code*

Country*

Phone*

Race (check as many as apply)*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Prefer not to answer

Email*

Ethnicity (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin, regardless of race.)*
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
Gender*
Female
Male
Prefer not to answer
Investigator Level*

Field of Expertise (e.g. obesity, palliative care, cancer care delivery)*

Are you engaged with a CCIS action group? If Yes, please indicate.*
Yes
No
CCIS action group affiliation (check all that apply)*
Community Participation in Implementation Science
Context and Equity in Implementation Science
Learning Healthcare Systems as Natural Laboratories
Implementation of Complex/Multilevel Interventions
Implementation Science in Global Health
Implementation Science Study Design
Policy and Implementation Science
Technology and Health Communication in Implementation Science
Are you a U.S. citizen?*
Yes
No
Are you new to the field of implementation science?*
Yes
No
Are you a federal employee?*
Yes
No
Supporting Documents

Please be sure to name all your files with your last name followed by an underscore and the type of
document (e.g., YourLastName_ProjectProposal, etc.) All documents must be either MS Word or Adobe
PDF files and should not exceed 1 MB in file size.
Project Proposal To Upload*

Personal Statement To Upload*

Curriculum Vitae To Upload*

Budget Proposal To Upload*