Form 1 Award Certificate

GPP AWARDS CERTIFICATE
OMB Clearance Number: 0925-0299
Expiration Date: 31 May 2024
Burden Time: 3 minutes
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 3 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.

Q01 First Name (Given Name):
________________________________________________________________

Q02 Last Name (Family Name):
________________________________________________________________

Q03 Your NIH Email Address:
________________________________________________________________

Q04 Your Permanent Email Address:
________________________________________________________________
Q05 Name as you would like it to appears on the Award Certificate:
________________________________________________________________

Q06 Graduate University:
________________________________________________________________

Q07 Graduate School / College Name:
________________________________________________________________

Q08 Graduate University Start Date (Month Year):
________________________________________________________________

Q09 Graduate University Stop Date (Month Year):
________________________________________________________________

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Q10 Degree Awarded / Anticipated:
o PhD
o MD, PhD
o DVM, PhD
o other, please specify __________________________________________________
Q11 Dissertation Title:
________________________________________________________________

Q12 University Research Advisor (Primary) - Full Name:
________________________________________________________________

Q13 University Research Advisor (Primary) - Email Address:
________________________________________________________________

Q14 University Research Advisor (Secondary) - Full Name:
________________________________________________________________
Q15 University Research Advisor (Secondary) - Email Address:
________________________________________________________________

Q16 Institute-Center:
▼ CC (1) ... OD

Q17 Campus Location:
o Bethesda, Maryland (Main Campus)
o Baltimore, Maryland (NIA and NIDA Campuses)
o Frederick, Maryland (NCI Section)
o Gaithersburg, Maryland (NCI Section)
o Poolesville, Maryland
o Rockville, Maryland (NIAID and NIAAA Sections)
o Framingham, Massachusetts (NHLBI Section)
o Research Triangle Park, North Carolina (NIEHS Campus)
o Hamilton, Montana (NIAID Section)
o Phoenix, Arizona (NIDDK Section)
o Other __________________________________________________
Q18 NIH Start Date as a PhD Graduate Student (Month Year):
________________________________________________________________

Q19 NIH Stop Date as a PhD Graduate Student (Month Year):
________________________________________________________________

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Q20 NIH Research Advisor (Principal Investigator) - Full Name:
________________________________________________________________
Q21 NIH Research Advisor (Principal Investigator) - Email Address:
________________________________________________________________

Q22 NIH Research Advisor (Daily Mentor, if applicable) - Full Name:
________________________________________________________________

Q23 NIH Research Advisor (Daily Mentor, if applicable) - Email Address:
________________________________________________________________

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