Form 1 HDRI Application

Conference, Meeting, Workshop, and Poster Session Registration Generic Clearance (OD)

HDRI application Final

2020 Health Disparities Research Institute (HDRI)

OMB: 0925-0740

Document [docx]
Download: docx | pdf

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.

Top of Form

APPLICANT INFORMATION

Name*

Shape1  Shape2  Shape3

Gender

Shape4  M

 

Shape5  F

Race

Shape6 American Indian or Alaska Native

Shape7 Asian

Shape8 Black or African American

Shape9 Native Hawaiian or other Pacific Islander

Shape10 White

Shape11 More than One Race

Ethnicity

Shape12 Hispanic or Latino

Shape13 Not Hispanic or Latino

Date of Birth

Shape14

Degrees/Credentials*

Shape15

Professional Title*

Shape16

Organization/Academic Institution*

Shape17

Department/Division*

Shape18

Mailing Address*

Shape19
Shape20  Shape21  Shape22

Daytime Phone*

Shape23

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*

Shape24 Academic Institution

Shape25 Community-based Organization

Shape26 Public Sector (state, local)

Shape27 Private Industry

Shape28 Non-Academic/Other Research Organization

NIH BIOSKETCH*

Upload your NIH Biosketch
(PDF Only)

Shape29 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.

Shape30 Clinical and Health Services Research (CHSR)

Shape31 Integrative Biological and Behavioral Research (IBBS)

Shape32 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)*

Shape33  Shape34  Shape35

Professional Title*

Shape36

Institution*

Shape37

Email*

Please double check your reference's email address.

Daytime Phone*

Shape38

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

Shape39 Select


Name (Reference 2)*

Shape40  Shape41  Shape42

Professional Title*

Shape43

Institution*

Shape44

Email*

Please double check your reference's email address.

Daytime Phone*

Shape45

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

Shape46 Select


How did you learn about this course?

Shape47 NIMHD website

Shape48 NIMHD listserv

Shape49 Professional organization

Shape50 Previous participant

Shape51 Social media (Facebook, Twitter)

Shape52 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.

Shape53 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



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorArtiles, Ligia (NIH/NIMHD) [E]
File Modified0000-00-00
File Created2021-01-13

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