7 form

KirschsteinNRSA Individual Fellowship Application (To be completed by fellowship applicant – follow PHS 416-1 instructions)

NAME OF APPLICANT (Last, first, middle initial)      

18. GOALS FOR KIRSCHSTEINNRSA FELLOWSHIP TRAINING AND CAREER

     

19. ACTIVITIES PLANNED UNDER THIS AWARD: Approximate percentage of proposed award time in activities identified below. (See instructions.)

Year

Research

Course Work

Teaching

Clinical

First

     

     

     

     

Second

     

     

     

     

Third

     

     

     

     

PREDOCTORAL FELLOWSHIPS ONLY

Fourth

     

     

     

     

Fifth

     

     

     

     

MD/PhD FELLOWSHIPS ONLY

Sixth

     

     

     

     

Briefly explain activities other than research and relate them to the proposed research training.      

20. PROJECT/PERFORMANCE SITE(S) Is the Primary Project/Performance Site the same as the Sponsoring Institution?

Yes

No

If No, provide detailed information below for the Primary Project/Performance Site Location

Organizational Name:

     

DUNS:

     

Street 1:

     

Street 2:

     

City:

     

County:

     

State:

     

Province:

     

Country:

     

Zip/Postal Code:

     

Project/Performance Site Congressional Districts:

     

21. HUMAN EMBRYONIC STEM CELLS

No

Yes

If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list: http://stemcells.nih.gov/research/registry/eligibilityCriteria.asp. Use continuation pages as needed. If a specific line cannot be referenced at this time, include a statement that one from the Registry will be used.

Cell Line

     

     

PHS 416-1 (Rev. xx/09) Page 3 Form Page 3