PHS Fellowship Supplemental Form (includes F reference letters)

PHS Applications and Pre-award Related Reporting (OD)

Attachment 15_eRA Commons Profile Data Elements.xlsx

PHS Fellowship Supplemental Form (includes F reference letters)

OMB: 0925-0001

Document [xlsx]
Download: xlsx | pdf

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
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