Form 1 Survey

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OMB No. 0925-0361
Form Approved for use through xx/xx/xxxx
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Applicant Information

NIH 2674-1
LRP Tracking Code:

Section 1. Identifying Information
The Loan Repayment Program is a competitive process and the submission of an application does not assure the award of benefits. Only
designated agents of the US Department of Health and Human Services/National Institutes of Health can make commitments for LRP awards.
Applicant's
Name:

Other Names
Used:
(e.g. Maiden)

First

Middle

Last

Suffix

First

Middle

Last

Suffix

Social Security Number:

-

Note: We collect your Social Security Number [SSN] to verify your identity,
to determine your eligibility for loan repayment assistance and to keep
track of the federal funds you receive. We also use your SSN for loan
repayment and servicing purposes under the Loan Repayment Program.
We also use this information to determine whether you are eligible for loan
repayment and the amount of that assistance. See Privacy Act
information for additional information.

-

NIH Commons User ID:

Optional: Please enter your 10 digit NIH Commons User ID

Section 2. Permanent (Home) Contact Information
Permanent (Home)
Address:

 US 




 Non-US




State
City

Telephone Number:



State

-

Zip Code

+4

-

(Area code required)

Fax Number:
(optional)

-

-

(Area code required)
Email:
(optional)

Instructions: If you do not have a home email
address, please insert your academic or work email
address in this box.

Section 3. Employment (or School) Contact Information
Position Title:



Select Title
Organization:
Division/School:
Department/Section:
 US 




 Non-US




Address:

State



City

Telephone Number:

State

-

-

Zip Code

+4

Ext:

(Area code required)

Alternate Contact Number:
(optional)

-

-

Ext:

(Area code required)
 Pager





 Cell





Fax Number:

-

-

(Area code required)

Email Address:
Please communicate with me at
my:

 Current (Work or School) Address.



 Permanent (Home) or 





Section 4. Education and Training
Please attach your Biosketch:

Attach File:

Browse...

You can upload a new file to
replace any previous Biosketch
you have uploaded until the
form is locked. This form will
only lock when you submit your
complete application.

Undergraduate Degree:

Important: It is not necessary to have a well-established career
to apply to this program. Please be sure to list significant
honors and grants in your Biosketch.
Click here for instructions on completing your Biosketch
and for a sample Biosketch. Do not exceed 5 pages.
Instructions: Click the "Browse" button and locate your file. We
accept most word processing document types.

Year





Degree

Major/Field of Specialization:
Conferring Institution:

Medical/Dental Degree:

Year



 NOTE: If MD/Ph.D. complete information for M.D. in this block and

Degree

information for Ph.D. separately under "Highest Graduate Degree."
Major/Field of Specialization:
Conferring Institution:

Instructions for Medical/Dental Specialty and Subspecialty Training: Select the area(s) in which you have
specialty or subspecialty training and indicate whether you are board eligible or certified in that area.
Specialty:
(optional)

Select a Specialty
Allergy and Immunology
- Clinical and Laboratory Immunology
Anesthesiology
- Pediatrics Anesthesiology
- Critical Care Medicine
- Pain Management





Board Eligible
 Yes 




 No



Board Certified
 Yes 




 No



Subspecialty:
(optional)

Select a Specialty
Allergy and Immunology
- Clinical and Laboratory Immunology
Anesthesiology
- Pediatrics Anesthesiology
- Critical Care Medicine
- Pain Management





Board Eligible
 Yes 




 No



Board Certified
 Yes 




 No



Highest Graduate Degree (1):

Year





Degree

Major/Field of Specialization:
Conferring Institution:
If Ph.D., please enter a synopsis
of your dissertation abstract
here:
(Please limit to 5000 characters,
including spaces - about 1 page)





Graduate Degree (2):

Year





Degree

Major/Field of Specialization:
Conferring Institution:

Graduate Degree (3):

Year





Degree

Major/Field of Specialization:
Conferring Institution:
* Text hidden if Intramural
Section 5. Federal Government Employment
Are you employed for more than
20 hours per week (5/8 or
greater) by a US Government
agency such as the NIH, CDC,
DOD, or the Veteran's
Administration?

 Yes (Please provide an explanation below) 




 No







Are you currently on a
fellowship supported in whole or
in part by a US Government
agency such as the Veteran's
Administration, CDC, or DOD?

 Yes (Please provide an explanation below) 




 No





Please answer "No" if you are
supported by a National
Research Service Award
(NRSA) Fellowship ( T32/F32 )
through the NIH.



Section 6. Service Obligation
Note: If you have a service obligation, you may still be eligible for LRP consideration if your service obligation has been or can be deferred for
the entire period of your LRP contract. For assistance, please call the LRP Helpline at 1-866-849-4047. Click here for examples of service
obligations.
Do you owe a service pay-back
obligation?

 Yes (Continue with questions below)




 No (Skip to Section 7)





Program Name:
When do you expect to fulfill
your obligation?







Note: Please answer "No" if you have received funding from a
T32/F32 National Research Service Award (NRSA) Fellowship and
list your NRSA Fellowship in Section 2 of the Funding Information
form.

Month

Day

Year

Section 7. Voluntary Disclosures
Completion of items in this section is VOLUNTARY. The information provided will be used to measure the extent to which members of these
groups are applying for and receiving NIH Loan Repayment Program contracts and/or for program evaluation. Failure to answer these
questions will have no effect on your consideration for these programs.


How did you learn about the NIH Loan Repayment Programs?
Gender/Ethnicity/Race/National Origin/Disability Status
Gender:
Are you Hispanic or Latino?

What is your racial
background?:

 Female 




 Male



 Yes





A person of Mexican, Puerto Rican, Cuban, Central or South
America, or other Spanish cultures or origins, regardless of race.
The term, “Spanish origin,” can be used in addition to “Hispanic or
Latino.”

 No





Name of Category
 American Indian or Alaska Native





(Check one or more)
 Asian





 Native Hawaiian or Other Pacific Islander




 Black or African American




 White





Definition of Category
A person having origins in any of the original peoples of North
American and South America (including Central America), and who
maintain cultural identification through community recognition or
tribal affiliation.
A person having origins in any of the original peoples of the Far
East, Southeast Asia, or the Indian subcontinent including, for
example, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.
A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
A person having origins in any of the black racial groups of Africa.
Terms such as “Haitian” or “Negro” can be used in addition to “Black
or African American.”
A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.

 Do Not Wish to Provide





Disability Status:



Select Disability Code

HANDICAP Definition: The physical or mental
impairment which substantially limits one or more
major life activities; the record of such impairment;
or the perception of such impairment by others.
Note: In the case of multiple impairments, the
code should indicate the impairment that results in
the most substantial limitation.



Date of Birth:



Month



Day



Year

Section 8. Certifications
Certification of Nondelinquent Status
The Federal Debt Collection Procedures Act of 1990 precludes a debtor who has a Federal judgment lien against his/her property arising from a Federal
debt from receiving Federal funds until the judgment is paid in full or otherwise satisfied. Applicants for the NIH Loan Repayment Programs must certify
that they do not have a judgment lien against their property arising from a debt to the United States.
I hereby certify that I [ 
 do] [ 



 do not] have a judgment lien against my property arising from a debt to the United States



I hereby certify that I [ 
 am] [ 



 am not] delinquent on any debt to the United States.




Certification of Accuracy of Information Provided
 I certify that the information given in this application is true, complete, and accurate to the best of my knowledge and does not omit any material




fact that would render the statement false, fictitious, or fraudulent as a result of the omission. I understand that the information given may be
investigated and that any false representation is sufficient cause for rejection of the application, or, if awarded loan repayment, that I am liable for
return of all awarded funds and, further, that any false statement my be punished as a felony under U.S Code, Title 18, Section 1001. I am aware
that any false, fraudulent, or fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under
the Program Fraud Civil Remedies Act of 1986.
I authorize any program to which I owe a service obligation to release information about that obligation to administrators of the NIH Loan
Repayment Program and to other authorized Government officials

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Public reporting for this collection of information is estimated to average 35 minutes, 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, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674-1
Privacy Act 09-25-0165

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