21 Attachment 7D PHS 416-1 Face Page 3

KirschsteinNRSA Individual Fellowship Application (To be completed by 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. TRAINING SITE(S) Is the Primary Training Site the same as the Sponsoring Institution?

Yes

No

If No, provide detailed information below for the Primary Training 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. 6/15) Page 3 Form Page 3