36 AIP application

ACADEMIC INTERNSHIP PROGRAM (AIP)
OMB Clearance Number: XXXX-XXXX
Expiration Date: XX-XXX-XXXX (not submission deadline) Burden
Time: 45 minutes

ACCOUNT INFORMATION
Name Prefix:
Mr.

Ms.

Mx.

First Name (Given Name):

Middle Initial:

Last Name (Family Name):

Email Address:

Phone - Primary:

Phone Type - Primary:
Cell

Landline

Phone - Secondary:

Phone Type - Secondary:
Cell

Landline

Password:

VALIDATION CODE QUESTIONS
What is your citizenship?:

What is your citizenship?:
US Citizen

US Permanent Resident

Foreign National

Will you be at least 17 years of age on the date you hope to begin the internship?
Yes

No

Is your school within 40 miles of the NIH campus on which you will intern?
Yes

No

Previous Experience at NIH:
0-3 months
months

3-6 months

18-21 months

6-9 months

21-24 months

9-12 months
24+ months

When do you hope to begin your internship?
Fall (August / September)

Spring (January / February)

Locations at which you would be willing to train?
LIST OF NIH CAMPUS LOCATIONS

RELATIVE AT NIH DISCLOSURE INFORMATION
Do you have relatives at NIH?
Yes

No

Relative's Name:

Relative's Relationship:
LIST OF RELATIVE RELATIONSHIPS
Relative's Institute-Center:

PERMANENT ADDRESS INFORMATION
Permanent Address - Line 1:

Permanent Address - Line 2:

Permanent City:

Permanent State:

12-15 months

15-18

Permanent Zip:

Permanent Country:

CURRENT ADDRESS INFORMATION
Current Address Same as Permanent Address:
Yes

No

Current Address - Line 1:

Current Address - Line 2:

Current Address City:

Current Address State:

Current Address Zip:

Current Address Country:

EDUCATION INFORMATION - CURRENT UNIVERSITY
Current University Education Degree Program:
Bachelor Program
Program

Masters Program

Veterinary Program

Dental Program

Nursing Program

Graduate Program

Current University Degree Awarded:
None

BA or BS

MA or MS

MD or DDS

DVM

PhD

Current University Education Year:
First Year

Second Year

Current University Name:

Third Year

Fourth Year

Fifth Year

Medical

Are you currently enrolled in this university?
Yes

No

During the internship, will you be enrolled and in good academic standing?:
Yes

No

Current University Academic Major:

Current University is Located in Which State:

Current University Start Date:
August

14

2020

Current University Stop Date:
August

14

2020

Current University Anticipated Degree Award Date:
August

14

2020

Current University Grade Point Average (GPA):

Current University Grade Point Average Scale:

Current University Coursework & Grades:

EDUCATION INFORMATION - PREVIOUS UNIVERSITY
Previous University Education Degree Program:
Bachelor Program
Program

Master Program

Veterinary Program

Dental Program

Nursing Program

Graduate Program

Previous University Degree Awarded:
None

BA or BS

MA or MS

MD or DDS

DVM

PhD

Medical

Previous University Name:

Previous University Academic Major:

Previous University Location:

Previous University Start Date:
August

14

2020

Previous University Stop Date:
August

14

2020

Previous University Grade Point Average (GPA):

Previous University Grade Point Average Scale:

Previous University Coursework & Grades:

CV / RESUME
Research Interest Key Words:

Personal Statement / Cover Letter:

Do you wish to apply for a particular Academic Internship Program?:

REFERENCE INFORMATION
Reference Prefix - 1:
Mr.

Mrs.

Ms.

Mx.

Dr.

Reference First Name -1:

Reference Last Name - 1:

Reference Phone - 1:

Reference Email - 1:

Resend Letter of Recommendation Request -1:
Yes

No

Reference Prefix -2:
Mr.

Mrs.

Ms.

Mx.

Dr.

Reference First Name -2:

Reference Last Name -2:

Reference Phone -2:

Reference Email -2:

Resend Letter of Recommendation Request -2:
Yes

No

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 45 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
(0925-0299). Do not return the completed form to this address.

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