Fillable Printable Phs 416-1Fp2 (Rev. 3/16), Form Page 2

Phs 416-1Fp2 (Rev. 3/16), Form Page 2

Kirschstein

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NRSA Individual Fellowship Application

(To be completed by applicant – follow PHS 416-1 instructions)

NAME O F APPLICANT (Last, first, middle initial)

SPONSOR and Co Sponsor Information

15. NAME OF SPONSOR 16. NAME OF Co-SPONSOR (When applicable)

15a. NAME AND DEGREE(S)

16a. NAME AND D EGREE(S)

15b. ERA COMMONS USER NAME

16b. ERA COMMONS USER NAME

15c. DEPARTMENT, SERVICE, LABORATOR Y, O R EQUIVALENT

16c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

15d. MAJOR SUBDIVISION

16d. MAJOR SUBDIVISION

15e. Address:

Telephone:

Fax:

E-Mail:

16e. Address:

Telephone:

Fax:

E-Mail:

RESEARCH PROPOSAL

17. DESCRIPTION: See instructions. State the application’s broad, long-term objectives and specific aims, making reference to the health

relatedness of the project (i.e., relevance to the mission of the agency). Describe concisely the research design and methods for achieving these

goals . Describe the rationale and techniques you will use to pursue these goals.

In addition, in two or three sentences, des cribe in plain, lay language the relevance of this research to public health. If the application is funded, this

description, as is, will become public information. Therefore, do not include proprietary/confidential information. DO NOT EXCEED THE SPACE

PROVIDED.

PHS 416-1 (Rev. 3/16) Page 2 Num ber pages consecutively at the bott om t hroughout Form Page 2

the application. Do not us e suffixes s uch as 2a, 2b.