A. Application Type:
From SF424 (R&R) Cover Page. The response provided on that page, regarding the type of application being submitted, is repeated here for your reference, as you attach the sections that are appropriate for this Career Development Award.
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New
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Resubmission
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Renewal
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Continuation
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Revision
B. Research Training Plan
1. Introduction to Application
(for RESUBMISSION applications only)
2. Specific Aims*
3. Research Strategy*
4. Progress Report Publication List
(for RENEWAL applications only)
Human Subjects
Please note. The following item is taken from the Research & Related Other Project Information form. The response provided on that page, regarding the involvement of human subjects, is repeated here for your reference as you provide related responses for this Fellowship application. If you wish to change the answer to the item shown below, please do so on the Research & Related Other Project Information form; you will not be able to edit the response here.
Are Human Subjects Involved?
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Yes
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No
5. Human Subjects Involvement Indefinite?
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Yes
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No
6. Clinical Trial?
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Yes
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No
7. Agency-Defined Phase III Clinical Trial?
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Yes
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No
8. Protection of Human Subjects
9. Inclusion of Women and Minorities
10. Inclusion of Children
Other Research Training Plan Sections
Please note. The following item is taken from the Research & Related Other Project Information form. The response provided on that page, regarding the use of vertebrate animals, is repeated here for your reference as you provide related responses for this Fellowship application. If you wish to change the answer to the item shown below, please do so on the Research & Related Other Project Information form; you will not be able to edit the response here.
Are Vertebrate Animals Used?
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Yes
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No
11. Vertebrate Animals Use Indefinite?
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Yes
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No
12. Vertebrate Animals
13. Select Agent Research
14. Resource Sharing Plan
17. Respective Contributions*
16. Selection of Sponsor and Institution*
17. Responsible Conduct of Research*
C. Additional Information
Human Embryonic Stem Cells
1. Does the proposed project involve human embryonic stem cells?*
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Yes
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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):
Fellowship Applicant
2. Alternate Phone Number:
3. Degree Sought During Proposed Award:
Degree:
If "other", please indicate degree type:
Expected Completion Date (month/year):
4. Field of Training for Current Proposal*:
5. Current Or Prior Kirschstein-NRSA Support?*
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Yes
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No
If yes, please identify current and prior Kirschstein-NRSA support below:
Level*
Type*
Start Date (if known)
End Date (if known)
Grant Number (if known)
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/
/
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/
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/
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6. Applications for Concurrent Support?*
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Yes
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No
If yes, please describe in an attached file:
7. Goals for Fellowship Training and Career*
8. Activities Planned Under This Award*
9. Doctoral Dissertation and Other Research Experience
10. Citizenship*
✔
U.S. Citizen or noncitizen national
✔
Permanent Resident of U.S. Pending
✔
Permanent Resident of U.S.
(If a permanent resident of the U.S., a notarized statement must be provided by the time of award)
✔
Non-U.S. Citizen with temporary U.S. visa
Institution
11.
✔
Change of Sponsoring Institution
Name of Former Institution:*
D. Sponsor(s) and Co-Sponsor(s)
Sponsor(s) and Co-Sponsor(s) Information*
E. Budget
All Fellowship Applicants:
1. Tuition and Fees*:
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None Requested
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Funds Requested
Year 1
$
Year 2
$
Year 3
$
Year 4
$
Year 5
$
Year 6 (when applicable)
$
Total Funds Requested:
$
Senior Fellowship Applicants Only:
2. Present Institutional Base Salary:
Amount
Academic Period
Number of Months
$
3. 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 (sabbatical leave, salary, etc.)
Source
F. Appendix
PHS Fellowship Supplemental Form
OMB Number: 0925-0002