Fillable Printable Phs 416-1Fp3 (Rev. 3/16), Form Page 3
Fillable Printable Phs 416-1Fp3 (Rev. 3/16), Form Page 3
Phs 416-1Fp3 (Rev. 3/16), Form Page 3
NAME O F APPLICANT (Last, first, middle initial)
Kirschstein
−
NRSA Individual Fellowship Applicatio n
(To be completed by applicant – follow PHS 416-1 instructions)
18. GO ALS FOR KIRSCHSTEIN−NRSA FELLOWSHIP TRAINING AN D CAREER
19. ACTIVITIES PLANNED UNDER THIS AWARD: Approximate percentage of proposed award time in activities identified below. (See instructions.)
Year
Research
Course Work
Teaching
Clinical
First
Second
Third
PREDOCTORAL FELLOWSHIPS ONLY
Fourth
Fifth
MD/P h D FE L L O WSHIPS O NL Y
Sixth
Briefly explain activities other than research and relate them to the proposed research training.
20. TRAINING SITE(S) Is the Primary Training Site the same as the Sponsoring Institution?
Yes
No
If No, provide detailed information below for the Primary Training Site Location
Organizational Name:
DUNS:
Street 1:
Street 2:
City:
County:
State:
Province:
Country:
Zip/Postal Code:
Project/Performance Site Congressional Districts:
21. HUMAN EMBRYONIC STEM CELLS
No Yes
If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list:
//stemcells.nih.gov/research/registry/eligibilityCriteria.asp. Use continuation pages as needed.
If a specific line cannot be r eferenced at t his time, include a statement that one from the Registry will be used.
Cell Line
PHS 416-1 (Rev. 3/16) Page 3 Form Page 3
