Form-09 NIH Graduate Partnerships Program Award Certificate

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NIH Graduate Partnerships Program Award Certificate
OMB Number: 0925-0299
Expiration Date: 31-March-2027
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. Completion of this collection form is voluntary and there are no penalties for not participating or withdrawing at any time. The collection information will be kept private to the extent provided by law. Information provided will be covered by the following SORNs: OPM/GOVT-1, OPM/GOVT-5, 09-90-0020, 09-25-0014, 09-25-0108, 09-25-0140, 09-25-0158, and 09-25-0165.

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.


        1. NIH Badge Number
		

        2. First Name (Given Name):
		

        3. Last Name (Family Name):
		

        4. Your NIH Email Address:
		

        5. Your Permanent Email Address:
		

        6. Name as you would like it to appear on the Award Certificate:
		

        7. Graduate University:
	

        8. Graduate School / College Name:
		

        9. Graduate University Start Date (Month-Year):
		

        10. Graduate University Stop Date (Month-Year):
		

        11. Degree Awarded / Anticipated
    • PhD
    • PsychD
    • PharmD
    • MD, PhD
    • DVM, PhD

        12. Dissertation Title:
		

        13. University Research Advisor (Primary) - Full Name:
		

        14. University Research Advisor (Primary) - Email Address:
		

        15. University Research Advisor (Secondary) - Full Name:
		

        16. University Research Advisor (Secondary) - Email Address:
		


        17. Institute-Center (acronym):
		

        18. NIH Campus Location:
    • Baltimore, MD		
    • Bethesda, MD
    • Frederick, MD
    • Gaithersburg, MD
    • Poolesville, MD
    • Rockville, MD
    • Framingham, MA
    • Research Triangle Park, NC
    • Hamilton, MT
    • Phoenix, AZ


        19. NIH Start Date as a PhD Graduate Student (Month Year):
		

        20. NIH Stop Date as a PhD Graduate Student (Month Year):
		

        21. NIH Research Advisor (Principal Investigator) - Full Name:
		

        22. NIH Research Advisor (Principal Investigator) - Email Address:
		

        23. NIH Research Advisor (Daily Mentor, if applicable) - Full Name:
		

        24. NIH Research Advisor (Daily Mentor, if applicable) - Email Address: