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pdfOMB No. 0925-0438
Form approved for use through xx/xx/xxxx
U.S. Department of Health and Human Services
National Institutes of Health
NIH Undergraduate Scholarship Program
Applicant’s Instructions:
Please complete Section A. Give this form and one of the envelopes
provided to three individuals who can assess your academic, scientific, and
other relevant skills and abilities.
Recommender’s Instructions:
Please complete Section B and return the form in the envelope provided,
or mail to National Institutes of Health Undergraduate Scholarship
Program, 2 Center Drive, Room 2E20 (MSC 0230), Bethesda, Maryland
20892-0230. If you have any questions, please call 888-352-3001 or
e-mail .
Applicant Information:
Recommendation
Section A — The applicant completes this section.
1. Applicant’s Name (last, first, middle) Please print.
2. Applicant’s Certification I certify that I am requesting a recommendation from an individual of my choosing which will be included in my NIH
Undergraduate Scholarship Program (UGSP) application. My application, including the completed recommendation forms submitted by my recommenders,
will be used by NIH officials to determine my eligibility for participation in the UGSP. I understand that the recommendation I am requesting shall be held in
confidence and protected from disclosure by officials of the NIH UGSP according to the Privacy Act System of Records 09-25-0165 (see Confidentiality and
Privacy Act Notice in this application package). I understand that by signing below, I will not have access to this recommendation, based on the promise of
confidentiality provided to my recommender in Section B of this form.
Applicant’s Signature (Sign your full name in ink.)
Date
__________________________________________________________________________________________________________________________
Section B — The recommender completes this section.
Please note that the information provided in this section shall be held in confidence and protected from disclosure by the officials of the NIH Scholarship
Program according to the Privacy Act System of Records 09-25-0165 only if the applicant’s signature appears above (see Privacy Act Notice in this
application package).
1. Name and Title of Recommender (Please print)
2. Name of Organization, Mailing Address, Telephone and E-Mail
3. How long have you known this applicant and in what capacity?
4. Please assess the applicant in the
categories below based on your relationship
and familiarity with the applicant compared to
other students in the same class year.
Superior
Among the
Top 1%
Outstanding
Among the
Top 5%
Excellent
Among the
Top 10%
Good
Among the
Top 331/3%
Average
Among the
Top 50%
Below
Average
Below the
Top 50%
N/A
No basis for
Judgment
Interest in science and research
Ability to complete projects accurately and timely
Writing skills
Analytical problem-solving skills
Oral communication skills
Rapport with peers
Rapport with faculty or supervisor
Ability to adapt to new situations
Initiative
Curiosity
Creativity
Observation skills
NIH 2762-2
PAGE 1 (FRONT)
Revised 08/07
Public reporting for this collection of information is estimated to average 3 hours and 10 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 (0925-0438). Do not return the completed form to this address.
OMB No. 0925-0438
Form approved for use through xx/xx/xxxx
5. Please assess the applicant’s potential for a career in biomedical, behavioral or social science research and share any observations and inferences
that would be useful in predicting this applicant’s potential to become a biomedical, behavioral or social science researcher. For example, your comments
may include your assessment of some of the following attributes: scientific aptitude, creativity, curiosity, initiative, work habits, and peer relationships.
6. The UGSP scholars will be required to fulfill two service obligations: (1) After each academic year of scholarship receipt, the UGSP scholars will be
required to work as NIH employees in the NIH research laboratories for 10 consecutive weeks during the months of June, July, and August. (2) Upon
graduation (unless a deferment is granted by the UGSP) scholars are required to begin their service obligation. UGSP scholars incur 1 year of obligated
service for each full or partial year of support and are obligated to serve as full-time NIH employees in an NIH research laboratory to fulfill this service
obligation. (The maximum service obligation is 4 years.)
Do you have any reason to believe that the applicant may NOT satisfy either of these service requirements? If so, please explain.
NIH 2762-2
PAGE 1 (BACK)
Revised 08/07
OMB No. 0925-0438
Form approved for use through xx/xx/xxxx
U.S. Department of Health and Human Services
National Institutes of Health
NIH Undergraduate Scholarship Program
Applicant’s Instructions:
Please complete Section A. Give this form and one of the envelopes
provided to three individuals who can assess your academic, scientific, and
other relevant skills and abilities.
Recommender’s Instructions:
Please complete Section B and return the form in the envelope provided,
or mail to National Institutes of Health Undergraduate Scholarship
Program, 2 Center Drive, Room 2E20 (MSC 0230), Bethesda, Maryland
20892-0230. If you have any questions, please call 888-352-3001 or
e-mail .
Applicant Information:
Recommendation
Section A — The applicant completes this section.
1. Applicant’s Name (last, first, middle) Please print.
2. Applicant’s Certification I certify that I am requesting a recommendation from an individual of my choosing which will be included in my NIH
Undergraduate Scholarship Program (UGSP) application. My application, including the completed recommendation forms submitted by my recommenders,
will be used by NIH officials to determine my eligibility for participation in the UGSP. I understand that the recommendation I am requesting shall be held in
confidence and protected from disclosure by officials of the NIH UGSP according to the Privacy Act System of Records 09-25-0165 (see Confidentiality and
Privacy Act Notice in this application package). I understand that by signing below, I will not have access to this recommendation, based on the promise of
confidentiality provided to my recommender in Section B of this form.
Applicant’s Signature (Sign your full name in ink.)
Date
__________________________________________________________________________________________________________________________
Section B — The recommender completes this section.
Please note that the information provided in this section shall be held in confidence and protected from disclosure by the officials of the NIH Scholarship
Program according to the Privacy Act System of Records 09-25-0165 only if the applicant’s signature appears above (see Privacy Act Notice in this
application package).
1. Name and Title of Recommender (Please print)
2. Name of Organization, Mailing Address, Telephone and E-Mail
3. How long have you known this applicant and in what capacity?
4. Please assess the applicant in the
categories below based on your relationship
and familiarity with the applicant compared to
other students in the same class year.
Superior
Among the
Top 1%
Outstanding
Among the
Top 5%
Excellent
Among the
Top 10%
Good
Among the
Top 331/3%
Average
Among the
Top 50%
Below
Average
Below the
Top 50%
N/A
No basis for
Judgment
Interest in science and research
Ability to complete projects accurately and timely
Writing skills
Analytical problem-solving skills
Oral communication skills
Rapport with peers
Rapport with faculty or supervisor
Ability to adapt to new situations
Initiative
Curiosity
Creativity
Observation skills
NIH 2762-2
PAGE 1 (FRONT)
Revised 08/07
Public reporting for this collection of information is estimated to average 3 hours and 10 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 (0925-0438). Do not return the completed form to this address.
OMB No. 0925-0438
Form approved for use through xx/xx/xxxx
5. Please assess the applicant’s potential for a career in biomedical, behavioral or social science research and share any observations and inferences
that would be useful in predicting this applicant’s potential to become a biomedical, behavioral or social science researcher. For example, your comments
may include your assessment of some of the following attributes: scientific aptitude, creativity, curiosity, initiative, work habits, and peer relationships.
6. The UGSP scholars will be required to fulfill two service obligations: (1) After each academic year of scholarship receipt, the UGSP scholars will be
required to work as NIH employees in the NIH research laboratories for 10 consecutive weeks during the months of June, July, and August. (2) Upon
graduation (unless a deferment is granted by the UGSP) scholars are required to begin their service obligation. UGSP scholars incur 1 year of obligated
service for each full or partial year of support and are obligated to serve as full-time NIH employees in an NIH research laboratory to fulfill this service
obligation. (The maximum service obligation is 4 years.)
Do you have any reason to believe that the applicant may NOT satisfy either of these service requirements? If so, please explain.
NIH 2762-2
PAGE 1 (BACK)
Revised 08/07
OMB No. 0925-0438
Form approved for use through xx/xx/xxxx
U.S. Department of Health and Human Services
National Institutes of Health
NIH Undergraduate Scholarship Program
Applicant’s Instructions:
Please complete Section A. Give this form and one of the envelopes
provided to three individuals who can assess your academic, scientific, and
other relevant skills and abilities.
Recommender’s Instructions:
Please complete Section B and return the form in the envelope provided,
or mail to National Institutes of Health Undergraduate Scholarship
Program, 2 Center Drive, Room 2E20 (MSC 0230), Bethesda, Maryland
20892-0230. If you have any questions, please call 888-352-3001 or
e-mail .
Applicant Information:
Recommendation
Section A — The applicant completes this section.
1. Applicant’s Name (last, first, middle) Please print.
2. Applicant’s Certification I certify that I am requesting a recommendation from an individual of my choosing which will be included in my NIH
Undergraduate Scholarship Program (UGSP) application. My application, including the completed recommendation forms submitted by my recommenders,
will be used by NIH officials to determine my eligibility for participation in the UGSP. I understand that the recommendation I am requesting shall be held in
confidence and protected from disclosure by officials of the NIH UGSP according to the Privacy Act System of Records 09-25-0165 (see Confidentiality and
Privacy Act Notice in this application package). I understand that by signing below, I will not have access to this recommendation, based on the promise of
confidentiality provided to my recommender in Section B of this form.
Applicant’s Signature (Sign your full name in ink.)
Date
__________________________________________________________________________________________________________________________
Section B — The recommender completes this section.
Please note that the information provided in this section shall be held in confidence and protected from disclosure by the officials of the NIH Scholarship
Program according to the Privacy Act System of Records 09-25-0165 only if the applicant’s signature appears above (see Privacy Act Notice in this
application package).
1. Name and Title of Recommender (Please print)
2. Name of Organization, Mailing Address, Telephone and E-Mail
3. How long have you known this applicant and in what capacity?
4. Please assess the applicant in the
categories below based on your relationship
and familiarity with the applicant compared to
other students in the same class year.
Superior
Among the
Top 1%
Outstanding
Among the
Top 5%
Excellent
Among the
Top 10%
Good
Among the
Top 331/3%
Average
Among the
Top 50%
Below
Average
Below the
Top 50%
N/A
No basis for
Judgment
Interest in science and research
Ability to complete projects accurately and timely
Writing skills
Analytical problem-solving skills
Oral communication skills
Rapport with peers
Rapport with faculty or supervisor
Ability to adapt to new situations
Initiative
Curiosity
Creativity
Observation skills
NIH 2762-2
PAGE 1 (FRONT)
Revised 08/07
Public reporting for this collection of information is estimated to average 3 hours and 10 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 (0925-0438). Do not return the completed form to this address.
OMB No. 0925-0438
Form approved for use through xx/xx/xxxx
5. Please assess the applicant’s potential for a career in biomedical, behavioral or social science research and share any observations and inferences
that would be useful in predicting this applicant’s potential to become a biomedical, behavioral or social science researcher. For example, your comments
may include your assessment of some of the following attributes: scientific aptitude, creativity, curiosity, initiative, work habits, and peer relationships.
6. The UGSP scholars will be required to fulfill two service obligations: (1) After each academic year of scholarship receipt, the UGSP scholars will be
required to work as NIH employees in the NIH research laboratories for 10 consecutive weeks during the months of June, July, and August. (2) Upon
graduation (unless a deferment is granted by the UGSP) scholars are required to begin their service obligation. UGSP scholars incur 1 year of obligated
service for each full or partial year of support and are obligated to serve as full-time NIH employees in an NIH research laboratory to fulfill this service
obligation. (The maximum service obligation is 4 years.)
Do you have any reason to believe that the applicant may NOT satisfy either of these service requirements? If so, please explain.
NIH 2762-2
PAGE 1 (BACK)
Revised 08/07
| File Type | application/pdf |
| File Title | T:\GRAPHICS\ILRSP\2007IL~1\UGSPAP~1\FORMS_~1\UGSP_AppPkt_checklist_0807.pmd |
| Author | lprelewicz |
| File Modified | 2008-02-14 |
| File Created | 2008-02-14 |