Form 1 Application

OMB No.: 0925-0761
Expiration Date: 07/31/2025
Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of participants are protected by The Privacy
Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing at any time. Refusal to participate will not affect your
benefits in any way. The information collected will be kept private to the extent provided by law. Names and other identifiers will not appear in any report.
Information provided will be combined for all participants and reported as summaries. You are being contacted to complete this form online so that we can
process your application for the Early Investigator Advancement (EIAP) program.
Public reporting burden for this collection of information is estimated to average 180 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 20892-7974, ATTN: PRA (0925-0761. Do not return the completed form to this address.