PHS Fellowship Supplemental Form (includes F reference letters)

---

Overview

Person Profile
Degree LOV

---

Sheet 1: Person Profile

Attachment 15 - eRA Commons Person Profile Data
Currently Collected on OMB Cleared Forms
OMB Clearance # 0925-0001
Field Name	Req Opt	Type of Field	LOV or Notes
Name and ID
Name Prefix	O	Text
First Name	R	Text
Middle Name or Initial	O	Text
Last Name	R	Text
Name Suffix	O	Text
eRA Email	R	Text
ORCID ID	R	Text	Will be a data feed from another system
Prior Name Prefix	O	Text
Prior First Name	O	Text	will be required if a prior name is to be added
Prior Middle Name or Initial	O	Text			User will be allowed to enter as many 'prior names' as they would like
Prior Last Name	O	Text	will be required if a prior name is to be added
Prior Name Suffix	O	Text
IDENTIFICATION
DOB (Include DNWTP option)	R	Date	DNWTP check provided
SSN (full or last 4)	O	Text
CITIZENSHIP STATUS
Citizenship Country	R	LOV	Country List
Status in the United States	R	Radio Buttons	US Citizen or Non-citizen National Permanent Resident of US Non-U.S. Citizen w/a temporary U.S. Visa Non-U.S. Citzen--Not Residing in the U.S.
DEMOGRAPHICS
Gender	R	Radio Buttons	Female Male DNWTP
Ethnicity and Race
Ethnicity	R	Radio Buttons	Hispanic/Latino Non-Hispanic DNWTP
Race	R	Checkboxes	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White DNWTP
Disability
Do you have?	R	Y/N
Type of Disability (Check all that apply)	R	Checkboxes	Vision Hearing Mobility/Orthopedic Other DNWTP
Disadvantaged Background?	R	Radio Buttons	No Yes DNWTP Not Applicable to me
TRAINING AND CAREER DEVELOPMENT SPECIFIC DATA
Non-Deliquency on US Federal Debt?	R	Radio Buttons	No Yes
Text Entry field if Yes		Text
EMPLOYMENT
Add a New Job
Employer: Select one:	R
I work in a company or institution outside NIH		Radio Button	When selected an LOV of organizations registered in the eRA Commons is available to select from
I work inside NIH		Radio Button	When selected, a LOV of NIH ICs is available
Start Date	R	Date
End Date	O	Date
Job Title	O	Text
About This Job
Primary Employment?	R	Checkbox
	R	Radio Button	Full-Time Part-Time
This is a job working directly for the federal government.	R	Radio Button	Yes No
This is a faculty teaching position.	O	Checkbox	If Checked, then the following Academic Rank LOV is used
Academic Rank	O	LOV	Assistant Professor Associate Professor Instructor Other Professor
This is an academic administrative position.	O	Checkbox	If Checked, then the following Position LOV is used
Position	O	LOV	Assistant or Associate Dean Chairperson of Dept (or Director) Dean Other President Vice President
Addresss & Contact Information
E-mail	R	Text
Phone	R	Text
Street Address Line 1	R	Text
Street Address Line 2	O	Text
City	R	Text
State	R	LOV	State List
ZipCode	R	Text
Country	R	LOV	Country List
Reviewer Information
What address should NIH use to contact you for reviews?		Radio Button	Options: Use my work address Use my home address
			Provide a different address If checked
Different Address
Street Address	R	Text
City	R	Text
State	R	LOV
ZipCode	R	Text
Country	R	LOV	Country List
Home Address
Street Address	R	Text
City	R	Text
State	R	LOV	State List
ZipCode	R	Text
Country	R	LOV	Country List
Eligibility for Continuous Submission		LOV	LOV updated annually.
TRAINEE PERMANENT ADDRESS
Street Address	R	Text
City	R	Text
State	R	LOV	State List
ZipCode	R	Text
Country	R	LOV	Country List
E-mail	R	Text
Phone	R	Text
EDUCATION
Degrees
Degree Name	R	LOV	See separate Tab for LOV
Degree Text (for Other)	O	Text
Status:		Radio Buttons
Degree Completed	R	Radio Buttons	w/Corresponding Date Field
In Progress, expected		Radio Buttons	w/Corresponding Date Field
Length of Program (# of Yrs)	O	LOV	1 - 9 Years
Institution	R	Text
Location (if not in US, indicate city & country)	O	Text
Is this your Terminal Research Degree?	O	Checkbox
Area of Study-Primary	O	Text
Area of Study-Secondary	O	Text
Area of Residency	O	Text
Residency Date Completed or Expected	R	Date
System Generated Fields
Fields used to aid in NI/ESI efforts. All are system-generated but part of the Person Profile
ESI Eligibility		Yes/No
End of Eligibility Date		Date
New Investigator Eligibility		Yes/No
Appeal Date		Date
Appeal Outcome		Text
Standard NI/ESI Eligibility is system calculated. However an exception policy has been implemented. These exceptions are handled via an appeal process.
Reference Ltrs
Referee First Name	R
Referee Last Name	R
Referee MI Name	O
Referee eMail	R
Referree Institution/Affliation	R
Referree Department	R
PI Commons User ID	R
PI Last Name	R
FOA Number	R
Reference Letter Confirmation # (if re-submitting)	O

---

Sheet 2: Degree LOV

Degrees LOV in Person Profile
AB	BACHELOR OF ARTS
BA	BACHELOR OF ARTS
BOTH	OTHER BACCALAUREATE
BS	BACHELOR OF SCIENCE
BSN	BACHELOR OF SCIENCE IN NURSING
DC	DOCTOR OF CHIROPRACTIC
DDOT	OTHER DOCTOR OF MEDICAL DENTISTRY
DDS	DOCTOR OF DENTAL SURGERY
DMD	DOCTOR OF MEDICAL DENTISTRY
DNSC	DOCTOR OF NURSING SCIENCE
DO	DOCTOR OF OSTEOPATHY
DOTH	OTHER DOCTORATE
DPH	DOCTOR OF PUBLIC HEALTH
DPM	DOCTOR OF PODIATRIC MEDICINE
DRPH	DOCTOR OF PUBLIC HEALTH
DSC	DOCTOR OF SCIENCE
DSW	DOCTOR OF SOCIAL WORK
DVM	DOCTOR OF VETERINARY MEDICINE
EDD	DOCTOR  OF EDUCATION
ENGD	FOREIGN - DOCTOR OF ENGINEERING
FAAN	FELLOW  OF THE AMERICAN ACADEMY OF NURSING
JD	DOCTOR OF JURIS PRUDENCE
MA	MASTER OF ARTS
MB	FOREIGN - BACHELOR OF MEDICINE
MBA	MASTER OF BUSINESS ADMINISTRATION
MBBS	FOREIGN - BACHELOR OF MEDICINE AND SURGERY
MD	DOCTOR OF MEDICINE
MDOT	OTHER DOCTOR OF MEDICINE
MLS	MASTER OF LIBRARY SCIENCE
MOTH	OTHER MASTERS
MPA	MASTER OF PUBLIC ADMINISTRATION
MPH	MASTER OF PUBLIC HEALTH
MS	MASTER OF SCIENCE
MSN	MASTER OF  SCIENCE IN NURSING
ND	DOCTOR OF NATUROPATHY
OD	DOCTOR OF OPTOMETRY
OTH	OTHER
PHD	DOCTOR OF PHILOSOPHY
PHMD	DOCTOR OF PHARMACY
PSYD	DOCTOR OF PSYCHOLOGY
RN	REGISTERED NURSE
SCD	DOCTOR OF SCIENCE
VDOT	OTHER DOCTOR OF VETERINARY MEDICINE
VMD	DOCTOR OF VETERINARY MEDICINE