Form 1 HDRI Application

OMB Number: 0925-0740 Expiration Date: 7/31/2022

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 Monday, March 9, 2020 (05:00pm EST).

Please complete the application below. Fields marked with an asterisk (*) are mandatory. 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.

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APPLICANT INFORMATION

Name*

   

Gender

 M

 

 F

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

More than One Race

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Date of Birth

Degrees/Credentials*

Professional Title*

Organization/Academic Institution*

Department/Division*

Mailing Address*

   

Daytime Phone*

Primary Email

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

Secondary Email*

Please provide a secondary email address.

Please identify your affiliation*

Academic Institution

Community-based Organization

Public Sector (state, local)

Private Industry

Non-Academic/Other Research Organization

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*

Email*

Please double check your reference's email address.

Daytime Phone*

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

Select

Name (Reference 2)*

   

Professional Title*

Institution*

Email*

Please double check your reference's email address.

Daytime Phone*

Submit Letter of Recommendation*
(PDF 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 August 3 through August 7, 2020.

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