|
IMPORTANT:
Write this Passkey Number on a piece of paper immediately and keep it in a safe location. You will need this Passkey Number to access your application to make changes:
4e417485-5ad3-400f-bbdd-415501489a7b
OMB #0925-0733
Expiration date 07/31/2022
|
|
NIDA International Program INVEST Postdoctoral Research Fellowships
Public reporting burden for this collection of information is estimated to 60 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 20902-7974, ATTN: PRA (0925-0733). Do not return the completed form to this address.
(Must be completed in English)
|
Application Type (Select One) *
|
|
First/ Given Name of Applicant *
|
Last/Family Name of Applicant *
|
Advanced Degree(s) *
|
Applicant Year of Birth (yyyy) *
|
|
Country of Citzenship (list both if dual citizen) *
|
Phone(xxx-xxx-xxxx) *
|
Primary E-mail *
|
Alternative E-mail
|
Position Title *
|
Name of Applicant's Institution *
|
Department, Service, Laboratory, or Equivalent *
|
Institution Mailing Address *
|
Permanent Home Address *
|
|
| |
| |
Colleague/Supervisor : 1 *
|
Name * (First/Given Name and Last/Family Name)
|
Email *
|
|
Colleague/Supervisor : 2 *
|
Name * (First/Given Name and Last/Family Name)
|
Email *
|
|
| |
| |
Name of Mentor * (First/Given Name and Last/Family Name)
|
Name of Mentor's Institution *
|
Institution Mailing Address *
|
Phone(xxx-xxx-xxxx) *
|
Mentor's Primary E-mail Address *
|
|
|
| |
| |
|
|
|
|
|
Current Employment
|
|
Name and Address of Current Employer* |
Job Title
* |
Employed From -
To (MM/YYYY) |
Please describe your current job responsibilities.
* |
|
|
|
*
/
|
|
|
Previous Employments |
Previous Employer(s)
|
Job Title(s)
|
Employment From-To (MM/YYYY) |
|
1.
|
|
/
|
|
2.
|
|
/
|
|
3.
|
|
/
|
|
4.
|
|
/
|
|
|
|
List your peer-reviewed publications (Recent 10).
|
|
|
|
List your significant honors, awards, projects, or other
accomplishments.
|
| |
| |
Fellowship Goals - Please provide a summary of your goals for
the fellowship (Limit to 500 characters). *
|
Research Proposal Abstract - Please limit your abstract to 2000 characters. *
|
Explain the research opportunities the institution and mentor offer that
are not currently available in your home country.
Describe key factors in your
selection of your mentor. *
|
Applicant's Full Research Plan
Applicants must submit a full research plan. Your plan may
not exceed three pages not including literature citations. Your plan should include:
(1) Specific aims
(2) Background and significance
(3) Research design and methods
(4) A statement of assurance that research presented in this application will
be conducted in compliance with NIH regulations on the conduct of research.
(5) Literature citations (Each citation must include the authors'
names, book or journal title, volume number, page numbers, and year of
publication).
Important Note: If you make any changes to your mentor statement and need to upload a new version, you must use a different name for the revised file. For
example, if the file name for your first mentor statement document was SamSmithMentorStatement, the file name for your revised document should be
SamSmithMentorStatement2.
Upload your research plan: Only PDF or MS Word Formats are accepted.
|
| |
| |
By checking the box,I,
, declare that I have read and understand the U.S.Federal regulations on the conduct of research supported
by the National Institutes of Health (NIH). I
certify that the statements herein are true, complete, and accurate to the best of
my knowledge, and I accept the obligation to comply with the terms and conditions if a
fellowship is awarded 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.
An incomplete certification and acceptance section, will disqualify your fellowship application.
|
|
|
This statement is provided pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a): The information requested in the applicant and mentor application forms as part of the International Research Fellowship Award Program is authorized to be collected pursuant to 42 USC 285, Chapter 6A, Subchapter III, Subpart 15 1320.3 Sections 405(b) (1) (C) of the PHS Act and 42 U.S.C. Sections 284 (b) (1) (C) ] and 285-287 Sections 405 (b) (1) (C) of the PHS Act and 42 U.S.C. Sections 284 (b) (1) (C)] and 285-287, Public Health and Welfare: Authorization of the National Institute on Drug Abuse the public health Service (PHS) Act (i.e., National Research Service Awards). Providing the requested information is voluntary, however, declining to provide any or all requested information may result in the denial of your application for the International Research Fellowship Award Program postdoctoral fellowship. The principal purpose for which the information will be used is to determine applicant and mentor eligibility for the International Research Fellowship Award Program postdoctoral fellowship. 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): 09-25-0036 Extramural Awards and Chartered Advisory Committees (IMPAC 2), Contact Information (DCIS), and Cooperative Agreement Information, HHS/NIH, https://www.hhs.gov/foia/privacy/sorns/nih-sorns.html.
|
