Form 1 Short-Term Research Experience for Underrepresented Pers

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

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OMB #0925-XXXX
Expiration Date: XX/XXXX
Short-Term Research Experience for Underrepresented Persons (STEP-UP) Application
Public reporting burden for this collection of information is estimated to average 45 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-xxxx*). Do
not return the completed form to this address.

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Mr. Test User Testing (TESTUSER)

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Member&Pro)ile
Of)icial&Name
Salutation

Mr.

First

Middle

Last

Permanent&Address
Street Line 1
Street Line 2
City
State

Select State

Zip Code

Day/Work Phone

(___) ___-____

Cell Phone

(___) ___-____

Home Phone

(___) ___-____

Contact

Email Address

Demographic&Information
Date of Birth

(mm/dd/yyyy)

Gender

Male

Hispanic?

Yes

Race/Ethnicity

White or Caucasian

Hispanic Nationality -- Select One -Specify*

* If you indicate your race/ethnicity as Native Hawaiian/Pacific Islander, American/Indian Alaska Native, Other Race or Two or
More Races, please specify.

Parent/Guradian&Contact&Information
Salutation

Mr.

First Name
Middle Name
Last Name
Day Phone

(___) ___-____

Cell Phone

(___) ___-____

Home Phone

(___) ___-____

Email
https://stepup.niddk.nih.gov/online/UpdateProfile.aspx

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Privacy&Act&Noti)ication&Statement
Collection of this information is authorized under 42 U.S.C. 241 and 5 U.S.C. 301. The primary use of this information is to provide short-term research
education for high school and undergraduate students from racial and ethnic minority or disadvantaged backgrounds in order to expose them to
research within the mission of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) at the National Institutes of Health (NIH)
and to determine their eligibility to receive grants. This information may be disclosed to NIH administrators, NIDDK Short-Term Research Experience
for Underrepresented Persons (STEP-UP) staff, university reviewers, and STEP-UP review committee members for administrative and educational
purposes. Submission of this information is voluntary, however, in order for us to consider you for enrollment in the STEP-UP program and potential
grant funding, you should complete all the required fields.

https://stepup.niddk.nih.gov/online/UpdateProfile.aspx

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