2 Preceptor Selection Verification Form

OMB No. 0925-0378
Form approved through 8/31/07

Preceptor Selection Verification Form
Applicant:

Last:

First:

MI:

Preceptor:

Last:

First:

MI:

Institute:
NIH/FDA Address

Street:
City:

State:

Zip code:

Year:

NIH/FDA Telephone:

I. Documentation of Resources
Prior approval is no longer required to sponsor a fellow for application to the PRAT Postdoctoral Fellowship Program.
Additionally, tenure track scientists are now allowed to sponsor PRAT Fellow applications. While preceptor preapplications have been discontinued, the prospective mentor's credentials will continue to be examined as part of the
joint application process. It is required that prospective preceptors supply a memo of recommendation from the
Laboratory/Branch Chief, through the Intramural Scientific Director, that incorporates information arising
from the most recent Board of Scientific Counselors’ review in enough detail so as to assure the prospective
preceptor’s future independent access to sufficient laboratory space and resources to serve as a mentor. A
brief description of the Mentor's Research Environment (laboratory space, equipment, core facilities,
scientific resources) and Training Record (number of current Postdocs and other trainees, names and current
positions of former Postdocs) should also be included.

IIA. Description of Research Environment

(Rev. 8/04)

OMB No. 0925-0378
Form approved through 8 /31/07

IIB. Documentation of Training Experience
Please provide a listing of the 15 most recent fellows who were trained in your laboratory in the last 5 years.

Dates Trained
Name of Fellow

From

To

Mo Yr Mo Yr

Present Position

Were you the
Official Supervisor
of Record?

III. SIGNATURE OF CONSENT
By my signature, I indicate that I intend to personally sponsor this fellow, if he/she is accepted into the PRAT
Program, and that I will provide regular guidance and mentorship, as well as access to suitable laboratory space and
resources. I have read and I approve of the fellow's proposed research plan. I understand that I can sponsor only one
PRAT application per year. I agree to submit my biographical sketch as part of the application process.
Signature of Preceptor:
Typed Name of Preceptor:

Fax or email this form to: PRAT Program Assistant
(301)480-2802
PRAT@NIGMS.NIH.GOV

OMB No. 0925-0378
Form approved through 8 /31/07

Preceptor Biographical Sketch
for Application to the
Pharmacology Research Associate Program

Name:

Position Title:

Education/Training
(Beginning with baccalaureate or other initial professional education, such as nursing, and include postdoctoral
training).
Degree
(If
Applicable)
Institution
City
State
Year
Field of Study

Research and Professional Experience:
Concluding with present position list, in chronological order, previous employment, experience, and honors. Include present membership on any
Federal Government public advisory committee. List, in chronological order, the titles, all authors, and complete references to all publications
during the past three years and to representative earlier publications pertinent to this application. If the list of publications in the last three years
exceeds 25,000 characters (including spaces), select the most pertinent publications. DO NOT EXCEED 25,000 CHARACTERS.