Form 1 2022HDRI application form

OMB Number: 0925-0740

Expiration Date: 7/31/2022

Privacy Act Statement

This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a):  Authority for the collection of the information requested from the recipient comes from the authorities regarding the establishment of the National Institutes of Health, its general authority to conduct and fund research and to provide training assistance, and its general authority to maintain records in connection with these and its other functions (42 U.S.C. 203, 241, 289l-1 and 44 U.S.C. 3101), and Section 301 and 493 of the Public Health Service Act. The purpose for which the information is intended is for the enrollment in to a program to support the career development of minority health/health disparities research scientists. The application requires personal information that is mandatory and failure to provide this information will result in not being considered for enrollment in to the NIMHD Health Disparities Research Institute. The information you provide will be included in a Privacy Act system of records, and will be used and may be disclosed for the purposes and routine uses described and published in the following System of Records Notice (SORN):  09-25-0156 Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD https://www.federalregister.gov/documents/2002/09/26/02-23965/privacy-act-of-1974-annual-publication-of-systems-of-records

Public reporting burden for this collection of information is estimated to average 25 minutes per submission. 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 0925-0740. Do not return the completed form to this address.

HEALTH DISPARITIES RESEARCH INSTITUTE APPLICATION

Applications are due ________________________(05:00pm EST).

Please complete the application below. Clicking “Save” at the bottom of the form will retain your progress for completing the application at a later time. Your application will not be complete until you click “Submit”. Incomplete applications will not be considered. Previous participants of the HDRI or the Translational Health Disparities Course are not eligible to apply.

Information on Gender, Race, Ethnicity is voluntary and will be used for reporting purposes.

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APPLICANT INFORMATION

Name

   

Gender

 M

 

 F

 Choose not to respond

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Degrees/Credentials

Professional Title

Organization/Academic Institution

Department/Division

State of residence

Daytime Phone

Primary Email

Your primary email address is automatically taken from your login ID.

Secondary Email

Please provide a secondary email address.

 

NIH BIOSKETCH

Upload your NIH Biosketch
(PDF Only)

Select

NIMHD Division of Scientific Program

Please select one NIMHD Division of Scientific Programs that aligns with the research proposed in your specific aims page.

Clinical and Health Services Research (CHSR)

Integrative Biological and Behavioral Research (IBBS)

Community Health and Population Sciences (CHPS)

PERSONAL STATEMENT

Submit a brief essay outlining career goals, reasons for participating in the program, and plans for obtaining NIH funding.

(350-word limit, copy and paste)

SPECIFIC AIMS PAGE

Submit a Specific Aims page that includes scientific premise/background, aims/hypotheses, and proposed methodology that reflects a future grant submission or resubmission that you plan to submit to NIH. To learn more about how to draft a specific aims page see these links: https://nihgrants.blogspot.com/2018/07/how-to-write-specific-aims-page.html or https://www.biosciencewriters.com/NIH-Grant-Applications-The-Anatomy-of-a-Specific-Aims-Page.aspx

(850-word limit, copy and paste)

REFERENCES

Please provide the following information on the persons who will serve as your references. References must be on letterhead and in PDF format for uploading (2-page limit) addressed to HDRI Selection Committee. One letter should be from a research mentor discussing the likelihood of grant submission within a year by the applicant

Name (Reference 1)

   

Professional Title

Institution

Submit Letter of Recommendation
(PDF signed, on letterhead, 2-page limit)

Select

Name (Reference 2)

   

Professional Title

Institution

Submit Letter of Recommendation
(PDF signed on letterhead, 2-page limit)

Select

How did you learn about this course?

NIMHD website

NIMHD listserv

Professional organization

Previous participant

Social media (Facebook, Twitter)

Other

Please note that the NIMHD Health Disparities Research Institute can accommodate only a limited number of applicants. An applicant who fails to attend after acceptance denies another worthy applicant the opportunity to participate. Therefore, if accepted, you assure the NIMHD that you will participate in the HDRI program from ________ through _______.

I have checked this box as proof that I have read and understand that if accepted, I will participate in the full HDRI program

NOTE: Failure to activate the SUBMIT button by the deadline will lead to an incomplete, ineligible application.

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Disclaimer: https://www.nimhd.nih.gov/disclaimer/

For more information, please contact: HDRI@nih.gov