Tracking Number:
Funding Opportunity Number:
. Received Date:
OMB Number: 0925-0001
Expiration Date: 03/31/2020
Introduction
1. Introduction to Application
(for Resubmission applications)
Fellowship Applicant Section
2. Applicant's Background and Goals for Fellowship Training*
Research Training Plan Section
3. Specific Aims*
4. Research Strategy*
5. Respective Contributions*
6. Selection of Sponsor and Institution*
7. Progress Report Publication List
(for Renewal applications)
8. Training in the Responsible Conduct of Research*
Sponsor(s), Collaborator(s) and Consultant(s) Section
9. Sponsor and Co-Sponsor Statements
10. Letters of Support from Collaborators, Contributors and Consultants
Institutional Environment and Commitment to Training Section
11. Description of Institutional Environment and Commitment to Training
Other Research Training Plan Section
Vertebrate Animals
The following item is taken from the Research & Related Other Project Information form and repeated here for your reference. Any change to this item must be made on the Research & Related Other Project Information form.
Are Vertebrate Animals Used?
✔
Yes
✔
No
12. Are vertebrate animals euthanized?
✔
Yes
✔
No
If "Yes" to euthanasia
Is method consistent with American Veterinary Medical Association (AVMA) guidelines?
✔
Yes
✔
No
If "No" to AVMA guidelines, describe method and provide scientific justification
13. Vertebrate Animals
Other Research Training Plan Information
14. Select Agent Research
15. Resource Sharing Plan
16. Authentication of Key Biological and/or Chemical Resources
Additional Information Section
17. Human Embryonic Stem Cells
Does the proposed project involve human embryonic stem cells?*
✔
Yes
✔
No
If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s), using the registry information provided within the agency instructions. Or, if a specific stem cell line cannot be referenced at this time, please check the box indicating that one from the registry will be used:
✔
Specific stem cell line cannot be referenced at this time. One from the registry will be used.
Cell Line(s):
18. Alternate Phone Number:
19. Degree Sought During Proposed Award:
Degree:
If "other", indicate degree type:
Expected Completion Date (MM/YYYY):
20. Field of Training for Current Proposal*:
21. Current or Prior Kirschstein-NRSA Support?*
✔
Yes
✔
No
If yes, identify current and prior Kirschstein-NRSA support below:
Level*
Type*
Start Date (if known)
End Date (if known)
Grant Number (if known)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
22. Applications for Concurrent Support?*
✔
Yes
✔
No
If yes, describe in an attached file:
23. Citizenship*
U.S. Citizen
U.S. Citizen or Non-Citizen National?
✔
Yes
✔
No
Non-U.S. Citizen
✔
With a Permanent U.S. Resident Visa
With a Permanent U.S. Resident Visa
✔
With a Temporary U.S. Visa
With a Temporary U.S. Visa
If you are a non-U.S. citizen with a temporary visa applying for an award that requires permanent residency status, and expect to be granted a permanent resident visa by the start date of the award, check here:
✔
24.
✔
Change of Sponsoring Institution
Name of Former Institution:*
Budget Section
All Fellowship Applicants:
25. Tuition and Fees*:
✔
None Requested
✔
Funds Requested
Year 1
$
Year 2
$
Year 3
$
Year 4
$
Year 5
$
Year 6 (when applicable)
$
Total Funds Requested:
$
Senior Fellowship Applicants Only:
26. Present Institutional Base Salary:
Amount
Academic Period
Number of Months
$
27. Stipends/Salary During First Year of Proposed Fellowship:
a. Federal Stipend Requested:
Amount
Number of Months
$
b. Supplementation from Other Sources:
Amount
Number of Months
$
Type (e.g.,sabbatical leave, salary)
Source
Appendix
28. Appendix
PHS Fellowship Supplemental Form