5 Attachment 7F PHS 416-1 Checklist Form Page

KirschsteinNRSA Individual Fellowship Application Checklist

NAME OF APPLICANT (Last, first, middle initial)      

To be completed by Applicant

A. TYPE OF APPLICATION

NEW application (This application is being submitted to the PHS for the first time.)

RESUBMISSION of application number

     

(This application replaces a prior unfunded version of a new or renewal application.)

RENEWAL of award number

     

(This application is to extend a funded award beyond its current award period.)

CHANGE of Sponsoring Institution

Name of former Institution:

     

B. ASSURANCES/CERTIFICATIONS

In signing the application Face Page, the authorized organizational representative agrees to comply with the policies, assurances and/or certifications listed in the application instructions when applicable. Descriptions of individual assurances/certifications are provided in Part III, and listed in Part I. If unable to certify compliance, where applicable, provide an explanation and place it after this page.

C. KIRSCHSTEINNRSA SENIOR FELLOWSHIP APPLICANTS ONLY

1. PRESENT INSTITUTIONAL BASE SALARY

Amount      

Academic Period/number of months      

2. STIPEND/SALARY DURING FIRST YEAR OF PROPOSED FELLOWSHIP

a. Stipend requested from PHS

Amount      

Number of months      

b. Supplementation from other sources

Amount      

Number of months      

Type (sabbatical leave, salary, etc.)      

Source      

D. TUITION and FEES

Predoctoral applicants should list estimated combined costs of tuition and fees. Postdoctoral applicants should list the estimated costs for the tuition and fees for courses planned that support the research training experience. For postdoctoral applicants, those courses should be described under Section D. Research Design and Methods of the Research Training Plan. Health insurance for predoctoral and postdoctoral fellowships is now paid as part of the institutional allowance. Senior Fellowship applicants should omit this section.

None Requested

Funds Requested:

Year – 01

Year – 02

Year – 03

Year – 04

Year – 05

Year – 06 (when applicable)

     

     

     

     

     

     

PHS 416-1 (Rev. 6/15) Page     Checklist Form Page