Form 19 Attachment 7B PHS 416-1 Face Page 1

** PHS 416-1 IS TO BE USED ONLY FOR A CHANGE OF SPONSORING INSTITUTION APPLICATION **

COMPETING NEW, RENEWAL OR RESUBMISSION FELLOWSHIP APPLICATIONS MUST USE THE SF424 (R&R) FELLOWSHIP APPLICATION PACKAGE AND APPLICATION GUIDE FOR ELECTRONIC SUBMISSION VIA GRANTS.GOV.  ANY NEW, RENEWAL OR RESUBMISSION APPLICATION SUBMITTED USING THE PHS 416-1 WILL BE RETURNED AND NOT REVIEWED.

Public reporting burden for this collection of information is estimated to average 10 hours 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 (0925-0001 and 0925-0002). Do not send applications to this address.

Form Approved Through 08/31/2015 OMB No. 0925-0001

Department of Health and Human Services Public Health Service Ruth L. Kirschstein National Research Service Award Individual Fellowship Application Follow instructions carefully. Do not exceed character length restrictions indicated.

LEAVE BLANK—For PHS use only.

Type

Activity

Number

Review Group

Formerly

Meeting Dates

Date Received

1. TITLE OF RESEARCH TRAINING PROPOSAL (Do not exceed 81 characters, including spaces and punctuation.)      

2. LEVEL OF FELLOWSHIP

3. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT (If “Yes,” state number and title)

NO YES

     

Number:

     

Title:

     

4a. NAME OF APPLICANT (Last, First, Middle)      

4b. ERA COMMONS USER NAME      

4c. HIGHEST DEGREE(S)

    

    

    

4d. PRESENT MAILING ADDRESS (Street, City, State, Zip Code)      

4e. PERMANENT MAILING ADDRESS (Street, City, State, Zip Code)      

4f. E-MAIL ADDRESS:

     

TELEPHONES AND FAX (Area code, number and extension)

4g. OFFICE      

4h. HOME      

4i. PERMANENT      

4j. FAX NUMBER      

4k.

U.S. CITIZEN OR U.S. NONCITIZEN NATIONAL

NONCITIZEN WITH A PERMANENT U.S. RESIDENT VISA

NONCITIZEN WITH TEMPORARY U.S. VISA

If you are a non-U.S citizen with a temporary visa who has applied for permanent resident status and expect to hold a permanent resident visa at the earliest possible start date, please also check here:

5. TRAINING UNDER PROPOSED AWARD (See Fields of Training)

6. PRIOR AND/OR CURRENT NRSA SUPPORT (Individual or Institutional) NO YES (If “Yes,” refer to item 22, Form Page 5)

Discipline No.:     

Subcategory Name:      

7a. DATES OF PROPOSED AWARD

7b. PROPOSED AWARD DURATION

8. DEGREE SOUGHT DURING PROPOSED AWARD

From (MM/DD/YY):      

Through (MM/DD/YY):      

(in months)   

Degree:      

Expected Completion Date:      

9. HUMAN SUBJECTS RESEARCH No Yes Indefinite

9b. Federalwide Assurance No.      

10. VERTEBRATE ANIMALS

No Yes

9c. Clinical Trial No Yes

9d. NIH-defined Phase III Clinical Trial No Yes

10a. Animal Welfare Assurance No.      

9a. Research Exempt No Yes If “Yes,” Exemption No.      

11. SPONSORING INSTITUTION

13. OFFICIAL SIGNING FOR SPONSORING INSTITUTION

Name

     

Name

     

Address

     

Title

     

Address

     

12a. ENTITY IDENTIFICATION NO.

12b. DUNS NO.

Tel:

     

Fax:

     

     

     

E-Mail:

     

14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete, and accurate to the best of my knowledge, and I agree to comply with the terms and conditions of award if an award is issued as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

SIGNATURE OF OFFICIAL NAMED IN 13. (In ink. “Per” signature not acceptable.)

DATE      

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