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<tbody>
<tr class="odd">
<td colspan="28">Form Approved Through 11/30/2010 OMB No. 0925-0001</td>
</tr>
<tr class="even">
<td colspan="12" rowspan="4"><p>Department of Health and Human
Services<br />
Public Health Services</p>
<h2 id="grant-application">Grant Application</h2>
<p>Do not exceed character length restrictions indicated.</p></td>
<td colspan="16"><strong>LEAVE BLANK—FOR PHS USE ONLY</strong>.</td>
</tr>
<tr class="odd">
<td colspan="5">Type</td>
<td colspan="5">Activity</td>
<td colspan="6">Number</td>
</tr>
<tr class="even">
<td colspan="10">Review Group</td>
<td colspan="6">Formerly</td>
</tr>
<tr class="odd">
<td colspan="10">Council/Board (Month, Year)</td>
<td colspan="6">Date Received</td>
</tr>
<tr class="even">
<td colspan="28"><p>1. TITLE OF PROJECT <em>(Do not exceed 81
characters, including spaces and punctuation.)</em></p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="28"><p>2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR
PROGRAM ANNOUNCEMENT OR SOLICITATION NO YES</p>
<p><em>(If “Yes,” state number and title)</em></p></td>
</tr>
<tr class="even">
<td colspan="2">Number:</td>
<td colspan="3">     </td>
<td colspan="2">Title:</td>
<td colspan="21">     </td>
</tr>
<tr class="odd">
<td colspan="12"><strong>3. PROGRAM DIRECTOR/PRINCIPAL
INVESTIGATOR</strong></td>
<td colspan="16"><strong>New Investigator</strong> <strong>No</strong>
<strong>Yes</strong></td>
</tr>
<tr class="even">
<td colspan="12">3a. NAME (Last, first, middle)</td>
<td colspan="9">3b. DEGREE(S)</td>
<td colspan="7">3h. eRA Commons User Name</td>
</tr>
<tr class="odd">
<td colspan="12"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="12"><p>3c. POSITION TITLE</p>
<blockquote>
<p>     </p>
</blockquote></td>
<td colspan="16" rowspan="3"><p>3d. MAILING ADDRESS <em>(Street, city,
state, zip code)</em></p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="12"><p>3e. DEPARTMENT, SERVICE, LABORATORY, OR
EQUIVALENT</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="12"><p>3f. MAJOR SUBDIVISION</p>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="12">3g. TELEPHONE AND FAX <em>(Area code, number and
extension)</em></td>
<td colspan="16">E-MAIL ADDRESS:</td>
</tr>
<tr class="even">
<td>TEL:</td>
<td colspan="5">     </td>
<td colspan="2">FAX:</td>
<td colspan="4">     </td>
<td colspan="16">     </td>
</tr>
<tr class="odd">
<td colspan="9">4. HUMAN SUBJECTS RESEARCH</td>
<td colspan="3">4a. Research Exempt</td>
<td colspan="16">If “Yes,” Exemption No.</td>
</tr>
<tr class="even">
<td colspan="9"> No Yes</td>
<td colspan="3"> No Yes</td>
<td colspan="16">     </td>
</tr>
<tr class="odd">
<td colspan="9">4b. Federal-Wide Assurance No.</td>
<td colspan="9">4c. Clinical Trial</td>
<td colspan="10">4d. NIH-defined Phase III Clinical Trial</td>
</tr>
<tr class="even">
<td colspan="9">     </td>
<td colspan="9"> No Yes</td>
<td colspan="10"> No Yes</td>
</tr>
<tr class="odd">
<td colspan="12">5. VERTEBRATE ANIMALS No Yes</td>
<td colspan="10">5a. Animal Welfare Assurance No.</td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="11"><p>6. DATES OF PROPOSED PERIOD OF</p>
<p>SUPPORT <em>(month, day, year—MM/DD/YY)</em></p></td>
<td colspan="9"><p>7. COSTS REQUESTED FOR INITIAL</p>
<p>BUDGET PERIOD</p></td>
<td colspan="8"><p>8. COSTS REQUESTED FOR PROPOSED</p>
<p>PERIOD OF SUPPORT</p></td>
</tr>
<tr class="odd">
<td colspan="4">From</td>
<td colspan="7">Through</td>
<td>7a. Direct Costs ($)</td>
<td colspan="8">7b. Total Costs ($)</td>
<td colspan="4">8a. Direct Costs ($)</td>
<td colspan="4">8b. Total Costs ($)</td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="7">     </td>
<td>     </td>
<td colspan="8">     </td>
<td colspan="4">     </td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="12">9. APPLICANT ORGANIZATION</td>
<td colspan="16">10. TYPE OF ORGANIZATION</td>
</tr>
<tr class="even">
<td colspan="3">Name</td>
<td colspan="9">     </td>
<td colspan="16"><blockquote>
<p>Public: Federal State Local</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="4">Address</td>
<td colspan="9" rowspan="4">     </td>
<td colspan="16"><blockquote>
<p>Private: Private Nonprofit</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="16"><blockquote>
<p>For-profit: General Small Business</p>
</blockquote>
<p> Woman-owned Socially and Economically Disadvantaged</p></td>
</tr>
<tr class="odd">
<td colspan="16"><p>11. ENTITY IDENTIFICATION NUMBER</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4">DUNS NO.</td>
<td colspan="5">     </td>
<td colspan="5">Cong. District</td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="12">12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS
MADE</td>
<td colspan="16">13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION</td>
</tr>
<tr class="even">
<td colspan="3">Name</td>
<td colspan="9">     </td>
<td colspan="2">Name</td>
<td colspan="14">     </td>
</tr>
<tr class="odd">
<td colspan="3">Title</td>
<td colspan="9">     </td>
<td colspan="2">Title</td>
<td colspan="14">     </td>
</tr>
<tr class="even">
<td colspan="3">Address</td>
<td colspan="9">     </td>
<td colspan="2">Address</td>
<td colspan="14">     </td>
</tr>
<tr class="odd">
<td>Tel:</td>
<td colspan="6">     </td>
<td colspan="3">FAX:</td>
<td colspan="2">     </td>
<td>Tel:</td>
<td colspan="10">     </td>
<td colspan="2">FAX:</td>
<td colspan="3">     </td>
</tr>
<tr class="even">
<td colspan="3">E-Mail:</td>
<td colspan="9">     </td>
<td colspan="2">E-Mail:</td>
<td colspan="14">     </td>
</tr>
<tr class="odd">
<td colspan="12">14. APPLICANT ORGANIZATION CERTIFICATION AND
ACCEPTANCE: I certify that the statements herein are true, complete and
accurate to the best of my knowledge, and accept the obligation to
comply with Public Health Services terms and conditions if a grant is
awarded as a result of this application. I am aware that any false,
fictitious, or fraudulent statements or claims may subject me to
criminal, civil, or administrative penalties.</td>
<td colspan="15"><p>SIGNATURE OF OFFICIAL NAMED IN 13.</p>
<p><em>(In ink. “Per” signature not acceptable.)</em></p></td>
<td><p>DATE</p>
<p>     </p></td>
</tr>
</tbody>
</table>

PHS 398 (Rev. 11/07) Face Page **Form Page 1**

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+---+---------------+---+--------------+----+----+----+----------------+
| 3 |               |   |              | 3  |    |    | 3h. NIH        |
| a |               |   |              | b. |    |    | Commons User   |
| . |               |   |              | D  |    |    | Name []{.mark} |
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| O |               |   |              |    |    |    |                |
| R |               |   |              |    |    |    |                |
| S |               |   |              |    |    |    |                |
| U |               |   |              |    |    |    |                |
| B |               |   |              |    |    |    |                |
| D |               |   |              |    |    |    |                |
| I |               |   |              |    |    |    |                |
| V |               |   |              |    |    |    |                |
| I |               |   |              |    |    |    |                |
| S |               |   |              |    |    |    |                |
| I |               |   |              |    |    |    |                |
| O |               |   |              |    |    |    |                |
| N |               |   |              |    |    |    |                |
|   |               |   |              |    |    |    |                |
|   |               |   |              |    |    |    |                |
|   |               |   |              |    |    |    |                |
|   |               |   |              |    |    |    |                |
|   |               |   |              |    |    |    |                |
|   |               |   |              |    |    |    |                |
+---+---------------+---+--------------+----+----+----+----------------+
| 3 |               |   |              | E- |    |    |                |
| g |               |   |              | MA |    |    |                |
| . |               |   |              | IL |    |    |                |
| T |               |   |              | AD |    |    |                |
| E |               |   |              | DR |    |    |                |
| L |               |   |              | ES |    |    |                |
| E |               |   |              | S: |    |    |                |
| P |               |   |              |    |    |    |                |
| H |               |   |              |    |    |    |                |
| O |               |   |              |    |    |    |                |
| N |               |   |              |    |    |    |                |
| E |               |   |              |    |    |    |                |
| A |               |   |              |    |    |    |                |
| N |               |   |              |    |    |    |                |
| D |               |   |              |    |    |    |                |
| F |               |   |              |    |    |    |                |
| A |               |   |              |    |    |    |                |
| X |               |   |              |    |    |    |                |
| * |               |   |              |    |    |    |                |
| ( |               |   |              |    |    |    |                |
| A |               |   |              |    |    |    |                |
| r |               |   |              |    |    |    |                |
| e |               |   |              |    |    |    |                |
| a |               |   |              |    |    |    |                |
| c |               |   |              |    |    |    |                |
| o |               |   |              |    |    |    |                |
| d |               |   |              |    |    |    |                |
| e |               |   |              |    |    |    |                |
| , |               |   |              |    |    |    |                |
| n |               |   |              |    |    |    |                |
| u |               |   |              |    |    |    |                |
| m |               |   |              |    |    |    |                |
| b |               |   |              |    |    |    |                |
| e |               |   |              |    |    |    |                |
| r |               |   |              |    |    |    |                |
| a |               |   |              |    |    |    |                |
| n |               |   |              |    |    |    |                |
| d |               |   |              |    |    |    |                |
| e |               |   |              |    |    |    |                |
| x |               |   |              |    |    |    |                |
| t |               |   |              |    |    |    |                |
| e |               |   |              |    |    |    |                |
| n |               |   |              |    |    |    |                |
| s |               |   |              |    |    |    |                |
| i |               |   |              |    |    |    |                |
| o |               |   |              |    |    |    |                |
| n |               |   |              |    |    |    |                |
| ) |               |   |              |    |    |    |                |
| * |               |   |              |    |    |    |                |
+---+---------------+---+--------------+----+----+----+----------------+
| T |               | F |              |    |    |    |                |
| E |               | A |              |    |    |    |                |
| L |               | X |              |    |    |    |                |
| : |               | : |              |    |    |    |                |
+---+---------------+---+--------------+----+----+----+----------------+

PHS 398 (Rev. 11/07) Face Page-continued **Form Page 1-continued**

  ----------------------- ------- ------- ------- ------------ ---------- ------- ------- --------- ------- -------- ------- ------------ -------- -------------
  Program                                                                                                                                          
  Director/Principal                                                                                                                               
  Investigator (Last,                                                                                                                              
  First, Middle):                                                                                                                                  

                                                                                                                                                   

  PROJECT SUMMARY (See                                                                                                                             
  instructions):                                                                                                                                   

                                                                                                                                                   

  RELEVANCE (See                                                                                                                                   
  instructions):                                                                                                                                   

                                                                                                                                                   

  PROJECT/PERFORMANCE                                                                                                                              
  SITE(S) (if additional                                                                                                                           
  space is needed, use                                                                                                                             
  Project/Performance                                                                                                                              
  Site Format Page)                                                                                                                                

  **Project/Performance                                                                                                                            
  Site Primary Location**                                                                                                                          

  Organizational Name:                                                                                                                             

  DUNS:                                                                                                                                            

  Street 1:                                                                                                 Street                                 
                                                                                                            2:                                     

  City:                                                                                   County:                                         State:        

  Province:                                                    Country:                                                      Zip/Postal                 
                                                                                                                             Code:                 

  Project/Performance                                                                                                                              
  Site Congressional                                                                                                                               
  Districts:                                                                                                                                       

                                                                                                                                                   

  **Additional                                                                                                                                     
  Project/Performance                                                                                                                              
  Site Location**                                                                                                                                  

  Organizational Name:                                                                                                                             

  DUNS:                                                                                                                                            

  Street 1:                                                                                                 Street                                 
                                                                                                            2:                                     

  City:                                                                                   County:                                         State:        

  Province:                                                    Country:                                                      Zip/Postal                 
                                                                                                                             Code:                 

  Project/Performance                                                                                                                              
  Site Congressional                                                                                                                               
  Districts:                                                                                                                                       
  ----------------------- ------- ------- ------- ------------ ---------- ------- ------- --------- ------- -------- ------- ------------ -------- -------------

PHS 398 (Rev. 11/07) Page [2]{.underline} **Form Page 2**

+-----------------+---+----+---------+---+-----------+---+---------------+
| Program         |   |    |         |   |           |   |               |
| Dir             |   |    |         |   |           |   |               |
| ector/Principal |   |    |         |   |           |   |               |
| Investigator    |   |    |         |   |           |   |               |
| (Last, First,   |   |    |         |   |           |   |               |
| Middle):        |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
| SENIOR/KEY      |   |    |         |   |           |   |               |
| PERSONNEL. See  |   |    |         |   |           |   |               |
| instructions.   |   |    |         |   |           |   |               |
| *Use            |   |    |         |   |           |   |               |
| continuation    |   |    |         |   |           |   |               |
| pages as        |   |    |         |   |           |   |               |
| needed* to      |   |    |         |   |           |   |               |
| provide the     |   |    |         |   |           |   |               |
| required        |   |    |         |   |           |   |               |
| information in  |   |    |         |   |           |   |               |
| the format      |   |    |         |   |           |   |               |
| shown below.    |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
| Start with      |   |    |         |   |           |   |               |
| Program         |   |    |         |   |           |   |               |
| Direct          |   |    |         |   |           |   |               |
| or(s)/Principal |   |    |         |   |           |   |               |
| I               |   |    |         |   |           |   |               |
| nvestigator(s). |   |    |         |   |           |   |               |
| List all other  |   |    |         |   |           |   |               |
| senior/key      |   |    |         |   |           |   |               |
| personnel in    |   |    |         |   |           |   |               |
| alphabetical    |   |    |         |   |           |   |               |
| order, last     |   |    |         |   |           |   |               |
| name first.     |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
| Name            |   | e  |         |   | Org       |   | Role on       |
|                 |   | RA |         |   | anization |   | Project       |
|                 |   | C  |         |   |           |   |               |
|                 |   | om |         |   |           |   |               |
|                 |   | mo |         |   |           |   |               |
|                 |   | ns |         |   |           |   |               |
|                 |   | Us |         |   |           |   |               |
|                 |   | er |         |   |           |   |               |
|                 |   | Na |         |   |           |   |               |
|                 |   | me |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
| OTHER           |   |    |         |   |           |   |               |
| SIGNIFICANT     |   |    |         |   |           |   |               |
| CONTRIBUTORS    |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
| Name            |   |    | Organ   |   |           | R |               |
|                 |   |    | ization |   |           | o |               |
|                 |   |    |         |   |           | l |               |
|                 |   |    |         |   |           | e |               |
|                 |   |    |         |   |           | o |               |
|                 |   |    |         |   |           | n |               |
|                 |   |    |         |   |           | P |               |
|                 |   |    |         |   |           | r |               |
|                 |   |    |         |   |           | o |               |
|                 |   |    |         |   |           | j |               |
|                 |   |    |         |   |           | e |               |
|                 |   |    |         |   |           | c |               |
|                 |   |    |         |   |           | t |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
| **Human         |   |    |         |   |           |   |               |
| Embryonic Stem  | * |    | **Yes** |   |           |   |               |
| Cells**         | * |    |         |   |           |   |               |
|                 | N |    |         |   |           |   |               |
|                 | o |    |         |   |           |   |               |
|                 | * |    |         |   |           |   |               |
|                 | * |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
| **If the        |   |    |         |   |           |   |               |
| proposed        |   |    |         |   |           |   |               |
| project         |   |    |         |   |           |   |               |
| involves human  |   |    |         |   |           |   |               |
| embryonic stem  |   |    |         |   |           |   |               |
| cells, list     |   |    |         |   |           |   |               |
| below the       |   |    |         |   |           |   |               |
| registration    |   |    |         |   |           |   |               |
| number of the   |   |    |         |   |           |   |               |
| specific cell   |   |    |         |   |           |   |               |
| line(s) from    |   |    |         |   |           |   |               |
| the following   |   |    |         |   |           |   |               |
| list:**         |   |    |         |   |           |   |               |
| <               |   |    |         |   |           |   |               |
| http://stemcell |   |    |         |   |           |   |               |
| s.nih.gov/resea |   |    |         |   |           |   |               |
| rch/registry/>. |   |    |         |   |           |   |               |
| *Use            |   |    |         |   |           |   |               |
| continuation    |   |    |         |   |           |   |               |
| pages as        |   |    |         |   |           |   |               |
| needed.*        |   |    |         |   |           |   |               |
|                 |   |    |         |   |           |   |               |
| If a specific   |   |    |         |   |           |   |               |
| line cannot be  |   |    |         |   |           |   |               |
| referenced at   |   |    |         |   |           |   |               |
| this time,      |   |    |         |   |           |   |               |
| include a       |   |    |         |   |           |   |               |
| statement that  |   |    |         |   |           |   |               |
| one from the    |   |    |         |   |           |   |               |
| Registry will   |   |    |         |   |           |   |               |
| be used.        |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
| **Cell Line**   |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
|                 |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+
| []{.mark}       |   |    |         |   |           |   |               |
+-----------------+---+----+---------+---+-----------+---+---------------+

PHS 398 (Rev. 11/07) Page [3]{.underline} **Form Page 2-continued**

Number the *following* pages consecutively throughout\
the application. Do not use suffixes such as 4a, 4b.

+----------------------------------+----------------------+---+---+---+---+
| Program Director/Principal       |                      |   |   |   |   |
| Investigator (Last, First,       |                      |   |   |   |   |
| Middle):                         |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| The name of the program          |                      |   |   |   |   |
| director/principal investigator  |                      |   |   |   |   |
| must be provided at the top of   |                      |   |   |   |   |
| each printed page and each       |                      |   |   |   |   |
| continuation page.               |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| # RESEARCH GRANT                 |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| # TABLE OF CONTENTS              |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
|                                  |                      |   | * |   |   |
|                                  |                      |   | P |   |   |
|                                  |                      |   | a |   |   |
|                                  |                      |   | g |   |   |
|                                  |                      |   | e |   |   |
|                                  |                      |   | N |   |   |
|                                  |                      |   | u |   |   |
|                                  |                      |   | m |   |   |
|                                  |                      |   | b |   |   |
|                                  |                      |   | e |   |   |
|                                  |                      |   | r |   |   |
|                                  |                      |   | s |   |   |
|                                  |                      |   | * |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Face Page                        |                      |   |   | 1 |   |
+----------------------------------+----------------------+---+---+---+---+
| Description, Project/Performance |                      |   |   | 2 |   |
| Sites, Senior/Key Personnel,     |                      |   |   |   |   |
| Other Significant Contributors,  |                      |   |   |   |   |
| and Human Embryonic Stem Cells   |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Table of Contents                |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Detailed Budget for Initial      |                      |   |   |   |   |
| Budget Period                    |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Budget for Entire Proposed       |                      |   |   |   |   |
| Period of Support                |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Budgets Pertaining to            |                      |   |   |   |   |
| Consortium/Contractual           |                      |   |   |   |   |
| Arrangements                     |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Biographical Sketch -- Program   |                      |   |   |   |   |
| Director/Principal Investigator  |                      |   |   |   |   |
| (*Not to exceed four pages       |                      |   |   |   |   |
| each*)                           |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Other Biographical Sketches (Not |                      |   |   |   |   |
| to exceed four pages each --     |                      |   |   |   |   |
| *See instructions*)              |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Resources                        |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Checklist                        |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Research Plan                    |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 1\. Introduction to Resubmission |                      |   |   |   |   |
| Application, if applicable *(Not |                      |   |   |   |   |
| to exceed three pages.),* or     |                      |   |   |   |   |
| Introduction to                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Revision Application, if         |                      |   |   |   |   |
| applicable *(Not to exceed one   |                      |   |   |   |   |
| page.)*                          |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 2\. Specific Aims                |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 3\. Background and Significance  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 4\. Preliminary Studies/Progress |                      |   |   |   |   |
| Report (Items 2-5: not to exceed |                      |   |   |   |   |
| 25 pages)                        |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
| Phase I Final Report             |                      |   |   |   |   |
| (SBIR/STTR), or                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
| SBIR/STTR Fast Track Product     |                      |   |   |   |   |
| Development Plan                 |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 5\. Research Design and Methods  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 6\. Inclusion Enrollment Report  |                      |   |   |   |   |
| (Renewal or Revision             |                      |   |   |   |   |
| applications only)               |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 7\. Bibliography and References  |                      |   |   |   |   |
| Cited/Progress Report            |                      |   |   |   |   |
| Publication List                 |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 8\. Protection of Human Subjects |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 9\. Inclusion of Women and       |                      |   |   |   |   |
| Minorities                       |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 10\. Targeted/Planned Enrollment |                      |   |   |   |   |
| Table                            |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 11\. Inclusion of Children       |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 12\. Vertebrate Animals          |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 13\. Select Agent Research       |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 14\. Multiple PD/PI Leadership   |                      |   |   |   |   |
| Plan                             |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 15\. Consortium/Contractual      |                      |   |   |   |   |
| Arrangements                     |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 16\. Letters of Support (e.g.,   |                      |   |   |   |   |
| Consultants)                     |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| 17\. Resource Sharing Plan (s)   |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+
| Appendix *(Five identical CDs.)* |                      |   |   | C |   |
|                                  |                      |   |   | h |   |
|                                  |                      |   |   | e |   |
|                                  |                      |   |   | c |   |
|                                  |                      |   |   | k |   |
|                                  |                      |   |   | i |   |
|                                  |                      |   |   | f |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   | A |   |
|                                  |                      |   |   | p |   |
|                                  |                      |   |   | p |   |
|                                  |                      |   |   | e |   |
|                                  |                      |   |   | n |   |
|                                  |                      |   |   | d |   |
|                                  |                      |   |   | i |   |
|                                  |                      |   |   | x |   |
|                                  |                      |   |   | i |   |
|                                  |                      |   |   | s |   |
|                                  |                      |   |   |   |   |
|                                  |                      |   |   | I |   |
|                                  |                      |   |   | n |   |
|                                  |                      |   |   | c |   |
|                                  |                      |   |   | l |   |
|                                  |                      |   |   | u |   |
|                                  |                      |   |   | d |   |
|                                  |                      |   |   | e |   |
|                                  |                      |   |   | d |   |
+----------------------------------+----------------------+---+---+---+---+
|                                  |                      |   |   |   |   |
+----------------------------------+----------------------+---+---+---+---+

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Form Page 3**

<table style="width:100%;">
<colgroup>
<col style="width: 18%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="6">Program Director/Principal Investigator (Last, First,
Middle):</td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="11" rowspan="2"><h1
id="detailed-budget-for-initial-budget-period">DETAILED BUDGET FOR
INITIAL BUDGET PERIOD</h1>
<h1 id="direct-costs-only">DIRECT COSTS ONLY</h1></td>
<td colspan="2">FROM</td>
<td colspan="3">THROUGH</td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="4">PERSONNEL <em>(Applicant organization only)</em></td>
<td colspan="5">Months Devoted to Project</td>
<td></td>
<td colspan="6">DOLLAR AMOUNT REQUESTED <em>(omit cents)</em></td>
</tr>
<tr class="even">
<td colspan="2">NAME</td>
<td colspan="2">ROLE ON<br />
PROJECT</td>
<td><p>Cal.</p>
<p>Mnths</p></td>
<td colspan="2"><p>Acad.</p>
<p>Mnths</p></td>
<td colspan="2"><p>Summer</p>
<p>Mnths</p></td>
<td>INST.BASE<br />
SALARY</td>
<td colspan="2">SALARY<br />
REQUESTED</td>
<td colspan="3">FRINGE<br />
BENEFITS</td>
<td>TOTAL</td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="2">PD/PI</td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="10"><blockquote>
<p>SUBTOTALS</p>
</blockquote></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="15"><p>CONSULTANT COSTS</p>
<p>     </p></td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="15"><p>EQUIPMENT <em>(Itemize)</em></p>
<p>     </p></td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="15"><p>SUPPLIES <em>(Itemize by category)</em></p>
<p>     </p></td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="15"><p>TRAVEL</p>
<p>     </p></td>
<td>     </td>
</tr>
<tr class="odd">
<td rowspan="2">PATIENT CARE COSTS</td>
<td colspan="2">INPATIENT</td>
<td colspan="12">     </td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2">OUTPATIENT</td>
<td colspan="12">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="15"><p>ALTERATIONS AND RENOVATIONS <em>(Itemize by
category)</em></p>
<p>     </p></td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="15"><p>OTHER EXPENSES <em>(Itemize by category)</em></p>
<p>     </p></td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="8">CONSORTIUM/CONTRACTUAL COSTS</td>
<td colspan="6">DIRECT COSTS</td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="14">SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD
<em>(Item 7a, Face Page)</em></td>
<td>$</td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="8">CONSORTIUM/CONTRACTUAL COSTS</td>
<td colspan="6">FACILITIES AND ADMINISTRATIVE COSTS</td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="14">TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD</td>
<td>$</td>
<td>     </td>
</tr>
</tbody>
</table>

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Form Page 4**

<table>
<colgroup>
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 15%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 15%" />
<col style="width: 14%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 13%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5">Program Director/Principal Investigator (Last, First,
Middle):</td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="11"><h1
id="budget-for-entire-proposed-project-period-direct-costs-only">BUDGET
FOR ENTIRE PROPOSED PROJECT PERIOD<br />
DIRECT COSTS ONLY</h1></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2">BUDGET CATEGORY<br />
TOTALS</td>
<td rowspan="2">INITIAL BUDGET<br />
PERIOD<br />
<em>(from Form Page 4)</em></td>
<td colspan="7">ADDITIONAL YEARS OF SUPPORT REQUESTED</td>
</tr>
<tr class="odd">
<td colspan="2">2nd</td>
<td>3rd</td>
<td colspan="2">4th</td>
<td colspan="2">5th</td>
</tr>
<tr class="even">
<td colspan="3">PERSONNEL: <em>Salary and fringe benefits. Applicant
organization only</em>.</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3">CONSULTANT COSTS</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3">EQUIPMENT</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3">SUPPLIES</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3">TRAVEL</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td rowspan="2">PATIENT CARE<br />
COSTS</td>
<td colspan="2">INPATIENT</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">OUTPATIENT</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="3">ALTERATIONS AND<br />
RENOVATIONS</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3">OTHER EXPENSES</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">CONSORTIUM/<br />
CONTRACTUAL<br />
COSTS</td>
<td>DIRECT</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3"><p>SUBTOTAL DIRECT COSTS</p>
<p><em>(Sum = Item 8a, Face Page)</em></p></td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">CONSORTIUM/<br />
CONTRACTUAL<br />
COSTS</td>
<td>F&amp;A</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="3">TOTAL DIRECT COSTS</td>
<td>     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="8">TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT
PERIOD</td>
<td colspan="2">$</td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="11"><p>JUSTIFICATION. Follow the budget justification
instructions exactly. Use continuation pages as needed.</p>
<p>     </p></td>
</tr>
</tbody>
</table>

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Form Page 5**

+-----------------------------------+-----------------------------------+
| Program Director/Principal        |                                   |
| Investigator (Last, First,        |                                   |
| Middle):                          |                                   |
+-----------------------------------+-----------------------------------+
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| # RESOURCES                       |                                   |
+-----------------------------------+-----------------------------------+
| FACILITIES: Specify the           |                                   |
| facilities to be used for the     |                                   |
| conduct of the proposed research. |                                   |
| Indicate the project/performance  |                                   |
| sites and describe capacities,    |                                   |
| pertinent capabilities, relative  |                                   |
| proximity, and extent of          |                                   |
| availability to the project. If   |                                   |
| research involving Select         |                                   |
| Agent(s) will occur at any        |                                   |
| performance site(s), the          |                                   |
| biocontainment resources          |                                   |
| available at each site should be  |                                   |
| described. Under "Other,"         |                                   |
| identify support services such as |                                   |
| machine shop, electronics shop,   |                                   |
| and specify the extent to which   |                                   |
| they will be available to the     |                                   |
| project. Use continuation pages   |                                   |
| if necessary.                     |                                   |
+-----------------------------------+-----------------------------------+
| Laboratory:                       |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| Clinical:                         |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| Animal:                           |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| Computer:                         |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| Office:                           |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| Other:                            |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+
| MAJOR EQUIPMENT: List the most    |                                   |
| important equipment items already |                                   |
| available for this project,       |                                   |
| noting the location and pertinent |                                   |
| capabilities of each.             |                                   |
|                                   |                                   |
|                                   |                                   |
+-----------------------------------+-----------------------------------+

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Resources Format Page**

<table>
<colgroup>
<col style="width: 20%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="13">Program Director/Principal Investigator (Last, First,
Middle):</td>
<td colspan="16">     </td>
</tr>
<tr class="even">
<td colspan="29"></td>
</tr>
<tr class="odd">
<td colspan="29"><h1 id="checklist">CHECKLIST</h1></td>
</tr>
<tr class="even">
<td colspan="29"><strong>TYPE OF APPLICATION</strong> <em>(Check all
that apply.)</em></td>
</tr>
<tr class="odd">
<td colspan="29"> NEW application. <em>(This application is being
submitted to the PHS for the first time.)</em></td>
</tr>
<tr class="even">
<td colspan="8"> RESUBMISSION of application number:</td>
<td colspan="21">     </td>
</tr>
<tr class="odd">
<td colspan="29"><blockquote>
<p><em>(This application replaces a prior unfunded version of a new,
renewal, or revision application.)</em></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="5"> RENEWAL of grant number:</td>
<td colspan="12">     </td>
<td colspan="5"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="22"><blockquote>
<p><em>(This application is to extend a funded grant beyond its current
project period.)</em></p>
</blockquote></td>
<td colspan="5"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5"> REVISION to grant number:</td>
<td colspan="11">     </td>
<td colspan="6"></td>
<td colspan="5"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="29"><blockquote>
<p><em>(This application is for additional funds to supplement a
currently funded grant.)</em></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="13"> CHANGE of program director/principal
investigator.</td>
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="11"><blockquote>
<p>Name of former program director/principal investigator:</p>
</blockquote></td>
<td colspan="18">     </td>
</tr>
<tr class="even">
<td colspan="11"> CHANGE of Grantee Institution. Name of former
institution:</td>
<td colspan="18">     </td>
</tr>
<tr class="odd">
<td> FOREIGN application</td>
<td colspan="14"> Domestic Grant with foreign involvement</td>
<td colspan="8">List Country(ies)<br />
Involved:</td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="29">INVENTIONS AND PATENTS <em>(Renewal appl. only)</em> No
Yes</td>
</tr>
<tr class="odd">
<td colspan="14">If “Yes,”</td>
<td colspan="15"> Previously reported Not previously reported</td>
</tr>
<tr class="even">
<td colspan="29"><p><strong>1. PROGRAM INCOME <em>(See
instructions.)</em></strong></p>
<p>All applications must indicate whether program income is anticipated
during the period(s) for which grant support is request. If program
income is anticipated, use the format below to reflect the amount and
source(s).</p></td>
</tr>
<tr class="odd">
<td colspan="4">Budget Period</td>
<td colspan="14">Anticipated Amount</td>
<td colspan="11">Source(s)</td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="14">     </td>
<td colspan="11">     </td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
<td colspan="14">     </td>
<td colspan="11">     </td>
</tr>
<tr class="even">
<td colspan="29"><p><strong>2. ASSURANCES/CERTIFICATIONS <em>(See
instructions.)</em></strong></p>
<p>In signing the application Face Page, the authorized organizational
representative agrees to comply with the policies, assurances and/or
certifications listed in the application instructions when applicable.
Descriptions of individual assurances/certifications are provided in
Part III and listed in Part I, 4.1 under Item 14. If unable to certify
compliance, where applicable, provide an explanation and place it after
this page.</p></td>
</tr>
<tr class="odd">
<td colspan="29"><strong>3. FACILITIES AND ADMINSTRATIVE COSTS
(F&amp;A)/ INDIRECT COSTS.</strong> See specific instructions.</td>
</tr>
<tr class="even">
<td colspan="2"> DHHS Agreement dated:</td>
<td colspan="17">     </td>
<td colspan="10"> No Facilities And Administrative Costs Requested.</td>
</tr>
<tr class="odd">
<td colspan="7"> DHHS Agreement being negotiated with</td>
<td colspan="18">     </td>
<td colspan="4">Regional Office.</td>
</tr>
<tr class="even">
<td colspan="10"> No DHHS Agreement, but rate established with</td>
<td colspan="15">     </td>
<td>Date</td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="29">CALCULATION* <em>(The entire grant application,
including the Checklist, will be reproduced and provided to peer
reviewers as confidential information.)</em></td>
</tr>
<tr class="even">
<td colspan="3">a. Initial budget period:</td>
<td colspan="6">Amount of base $</td>
<td colspan="3">     </td>
<td colspan="8">x Rate applied</td>
<td colspan="5">     </td>
<td colspan="3">% = F&amp;A costs $</td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="3">b. 02 year</td>
<td colspan="6">Amount of base $</td>
<td colspan="3">     </td>
<td colspan="8">x Rate applied</td>
<td colspan="5">     </td>
<td colspan="3">% = F&amp;A costs $</td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="3">c. 03 year</td>
<td colspan="6">Amount of base $</td>
<td colspan="3">     </td>
<td colspan="8">x Rate applied</td>
<td colspan="5">     </td>
<td colspan="3">% = F&amp;A costs $</td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="3">d. 04 year</td>
<td colspan="6">Amount of base $</td>
<td colspan="3">     </td>
<td colspan="8">x Rate applied</td>
<td colspan="5">     </td>
<td colspan="3">% = F&amp;A costs $</td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="3">e. 05 year</td>
<td colspan="6">Amount of base $</td>
<td colspan="3">     </td>
<td colspan="8">x Rate applied</td>
<td colspan="5">     </td>
<td colspan="3">% = F&amp;A costs $</td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="24"></td>
<td colspan="4">TOTAL F&amp;A Costs $</td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="29">*Check appropriate box(es):</td>
</tr>
<tr class="odd">
<td colspan="6"> Salary and wages base</td>
<td colspan="15"> Modified total direct cost base</td>
<td colspan="8"> Other base <em>(Explain)</em></td>
</tr>
<tr class="even">
<td colspan="29"> Off-site, other special rate, or more than one rate
involved <em>(Explain)</em></td>
</tr>
<tr class="odd">
<td colspan="29">Explanation <em>(Attach separate sheet, if
necessary.):</em></td>
</tr>
<tr class="even">
<td colspan="29">     </td>
</tr>
<tr class="odd">
<td colspan="29"><strong>4. DISCLOSURE PERMISSION STATEMENT:</strong> If
this application does not result in an award, is the Government
permitted to disclose the title of your proposed project, and the name,
address, telephone number and e-mail address of the official signing for
the applicant organization, to organizations that may be interested in
contacting you for further information (e.g., possible collaborations,
investment)? Yes No</td>
</tr>
<tr class="even">
<td colspan="29"></td>
</tr>
</tbody>
</table>

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Checklist Form Page**

+---+---+------------+------+-------+---+------------------------------+
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+---+---+------------+------+-------+---+------------------------------+
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| D |   |            |      |       |   | SEX/GENDER                   |
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| T |   |            |      |       |   | Female Male                  |
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+---+---+------------+------+-------+---+------------------------------+
| S |   |            | XXX  |       |   |                              |
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+---+---+------------+------+-------+---+------------------------------+
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+---+---+------------+------+-------+---+------------------------------+
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| n |   |            |      |       |   |                              |
| i |   |            |      |       |   |                              |
| t |   |            |      |       |   |                              |
| i |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| n |   |            |      |       |   |                              |
| b |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| l |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| w |   |            |      |       |   |                              |
| . |   |            |      |       |   |                              |
| ) |   |            |      |       |   |                              |
| S |   |            |      |       |   |                              |
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| l |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| c |   |            |      |       |   |                              |
| t |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| n |   |            |      |       |   |                              |
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| . |   |            |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | *          |      |       |   |                              |
|   |   | **Hispanic |      |       |   |                              |
|   |   | or         |      |       |   |                              |
|   |   | Latino.*** |      |       |   |                              |
|   |   | A person   |      |       |   |                              |
|   |   | of         |      |       |   |                              |
|   |   | Mexican,   |      |       |   |                              |
|   |   | Puerto     |      |       |   |                              |
|   |   | Rican,     |      |       |   |                              |
|   |   | Cuban,     |      |       |   |                              |
|   |   | South or   |      |       |   |                              |
|   |   | Central    |      |       |   |                              |
|   |   | American,  |      |       |   |                              |
|   |   | or other   |      |       |   |                              |
|   |   | Spanish    |      |       |   |                              |
|   |   | culture or |      |       |   |                              |
|   |   | origin,    |      |       |   |                              |
|   |   | regardless |      |       |   |                              |
|   |   | of race.   |      |       |   |                              |
|   |   | The term,  |      |       |   |                              |
|   |   | "Spanish   |      |       |   |                              |
|   |   | origin,"   |      |       |   |                              |
|   |   | can be     |      |       |   |                              |
|   |   | used in    |      |       |   |                              |
|   |   | addition   |      |       |   |                              |
|   |   | to         |      |       |   |                              |
|   |   | "Hispanic  |      |       |   |                              |
|   |   | or         |      |       |   |                              |
|   |   | Latino."   |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | **Hispanic |      |       |   |                              |
|   |   | or         |      |       |   |                              |
|   |   | Latino**   |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | **Not      |      |       |   |                              |
|   |   | Hispanic   |      |       |   |                              |
|   |   | or         |      |       |   |                              |
|   |   | Latino**   |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   |            |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
| R |   |            |      |       |   |                              |
| A |   |            |      |       |   |                              |
| C |   |            |      |       |   |                              |
| E |   |            |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
| * |   |            |      |       |   |                              |
| * |   |            |      |       |   |                              |
| 2 |   |            |      |       |   |                              |
| . |   |            |      |       |   |                              |
| * |   |            |      |       |   |                              |
| * |   |            |      |       |   |                              |
| W |   |            |      |       |   |                              |
| h |   |            |      |       |   |                              |
| a |   |            |      |       |   |                              |
| t |   |            |      |       |   |                              |
| r |   |            |      |       |   |                              |
| a |   |            |      |       |   |                              |
| c |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| d |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| y |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| u |   |            |      |       |   |                              |
| c |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| n |   |            |      |       |   |                              |
| s |   |            |      |       |   |                              |
| i |   |            |      |       |   |                              |
| d |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| r |   |            |      |       |   |                              |
| y |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| u |   |            |      |       |   |                              |
| r |   |            |      |       |   |                              |
| s |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| l |   |            |      |       |   |                              |
| f |   |            |      |       |   |                              |
| t |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| b |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| ? |   |            |      |       |   |                              |
| S |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| l |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| c |   |            |      |       |   |                              |
| t |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| n |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| r |   |            |      |       |   |                              |
| m |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| r |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| f |   |            |      |       |   |                              |
| t |   |            |      |       |   |                              |
| h |   |            |      |       |   |                              |
| e |   |            |      |       |   |                              |
| f |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| l |   |            |      |       |   |                              |
| l |   |            |      |       |   |                              |
| o |   |            |      |       |   |                              |
| w |   |            |      |       |   |                              |
| i |   |            |      |       |   |                              |
| n |   |            |      |       |   |                              |
| g |   |            |      |       |   |                              |
| . |   |            |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | *          |      |       |   |                              |
|   |   | **American |      |       |   |                              |
|   |   | Indian or  |      |       |   |                              |
|   |   | Alaska     |      |       |   |                              |
|   |   | Native.*** |      |       |   |                              |
|   |   | A person   |      |       |   |                              |
|   |   | having     |      |       |   |                              |
|   |   | origins in |      |       |   |                              |
|   |   | any of the |      |       |   |                              |
|   |   | original   |      |       |   |                              |
|   |   | peoples of |      |       |   |                              |
|   |   | North,     |      |       |   |                              |
|   |   | Central,   |      |       |   |                              |
|   |   | **or**     |      |       |   |                              |
|   |   | South      |      |       |   |                              |
|   |   | America,   |      |       |   |                              |
|   |   | and who    |      |       |   |                              |
|   |   | maintains  |      |       |   |                              |
|   |   | tribal     |      |       |   |                              |
|   |   | a          |      |       |   |                              |
|   |   | ffiliation |      |       |   |                              |
|   |   | or         |      |       |   |                              |
|   |   | community  |      |       |   |                              |
|   |   | a          |      |       |   |                              |
|   |   | ttachment. |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | **         |      |       |   |                              |
|   |   | *Asian.*** |      |       |   |                              |
|   |   | A person   |      |       |   |                              |
|   |   | having     |      |       |   |                              |
|   |   | origins in |      |       |   |                              |
|   |   | any of the |      |       |   |                              |
|   |   | original   |      |       |   |                              |
|   |   | peoples of |      |       |   |                              |
|   |   | the Far    |      |       |   |                              |
|   |   | East,      |      |       |   |                              |
|   |   | Southeast  |      |       |   |                              |
|   |   | Asia, or   |      |       |   |                              |
|   |   | the\       |      |       |   |                              |
|   |   | Indian     |      |       |   |                              |
|   |   | **subco    |      |       |   |                              |
|   |   | ntinent**, |      |       |   |                              |
|   |   | including, |      |       |   |                              |
|   |   | for        |      |       |   |                              |
|   |   | example,   |      |       |   |                              |
|   |   | Cambodia,  |      |       |   |                              |
|   |   | China,     |      |       |   |                              |
|   |   | India,     |      |       |   |                              |
|   |   | Japan,     |      |       |   |                              |
|   |   | Korea,     |      |       |   |                              |
|   |   | Malaysia,  |      |       |   |                              |
|   |   | Pakistan,  |      |       |   |                              |
|   |   | the        |      |       |   |                              |
|   |   | P          |      |       |   |                              |
|   |   | hilippine\ |      |       |   |                              |
|   |   | Islands,   |      |       |   |                              |
|   |   | Thailand,  |      |       |   |                              |
|   |   | and        |      |       |   |                              |
|   |   | Vietnam.   |      |       |   |                              |
|   |   | (Note:     |      |       |   |                              |
|   |   | I          |      |       |   |                              |
|   |   | ndividuals |      |       |   |                              |
|   |   | from the   |      |       |   |                              |
|   |   | Philippine |      |       |   |                              |
|   |   | Islands    |      |       |   |                              |
|   |   | have been  |      |       |   |                              |
|   |   | recorded   |      |       |   |                              |
|   |   | as Pacific |      |       |   |                              |
|   |   | Islanders  |      |       |   |                              |
|   |   | in         |      |       |   |                              |
|   |   | previous   |      |       |   |                              |
|   |   | data       |      |       |   |                              |
|   |   | collection |      |       |   |                              |
|   |   | st         |      |       |   |                              |
|   |   | rategies.) |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | ***Black   |      |       |   |                              |
|   |   | or African |      |       |   |                              |
|   |   | Am         |      |       |   |                              |
|   |   | erican.*** |      |       |   |                              |
|   |   | A person   |      |       |   |                              |
|   |   | having     |      |       |   |                              |
|   |   | origins in |      |       |   |                              |
|   |   | any of the |      |       |   |                              |
|   |   | black      |      |       |   |                              |
|   |   | racial     |      |       |   |                              |
|   |   | groups of  |      |       |   |                              |
|   |   | Africa.    |      |       |   |                              |
|   |   | Terms such |      |       |   |                              |
|   |   | as         |      |       |   |                              |
|   |   | "Haitian"  |      |       |   |                              |
|   |   | or "Negro" |      |       |   |                              |
|   |   | can be     |      |       |   |                              |
|   |   | used in    |      |       |   |                              |
|   |   | addition   |      |       |   |                              |
|   |   | to "Black" |      |       |   |                              |
|   |   | or African |      |       |   |                              |
|   |   | American." |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | ***Native  |      |       |   |                              |
|   |   | Hawaiian   |      |       |   |                              |
|   |   | or Other   |      |       |   |                              |
|   |   | Pacific    |      |       |   |                              |
|   |   | Is         |      |       |   |                              |
|   |   | lander.*** |      |       |   |                              |
|   |   | A person   |      |       |   |                              |
|   |   | having     |      |       |   |                              |
|   |   | origins in |      |       |   |                              |
|   |   | any of the |      |       |   |                              |
|   |   | original   |      |       |   |                              |
|   |   | peoples of |      |       |   |                              |
|   |   | Hawaii,    |      |       |   |                              |
|   |   | Guam,      |      |       |   |                              |
|   |   | Samoa, or  |      |       |   |                              |
|   |   | **other**  |      |       |   |                              |
|   |   | Pacific    |      |       |   |                              |
|   |   | Islands.   |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | **         |      |       |   |                              |
|   |   | *White.*** |      |       |   |                              |
|   |   | A          |      |       |   |                              |
|   |   | **person** |      |       |   |                              |
|   |   | having     |      |       |   |                              |
|   |   | origins in |      |       |   |                              |
|   |   | any of the |      |       |   |                              |
|   |   | original   |      |       |   |                              |
|   |   | peoples of |      |       |   |                              |
|   |   | Europe,    |      |       |   |                              |
|   |   | the Middle |      |       |   |                              |
|   |   | East, or   |      |       |   |                              |
|   |   | North      |      |       |   |                              |
|   |   | Africa.    |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   | Check here |      |       |   |                              |
|   |   | if you do  |      |       |   |                              |
|   |   | not wish   |      |       |   |                              |
|   |   | to provide |      |       |   |                              |
|   |   | some or    |      |       |   |                              |
|   |   | all of the |      |       |   |                              |
|   |   | above      |      |       |   |                              |
|   |   | in         |      |       |   |                              |
|   |   | formation. |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+
|   |   |            |      |       |   |                              |
+---+---+------------+------+-------+---+------------------------------+

PHS 398 (Rev. 11/07) DO NOT PAGE NUMBER THIS FORM **Personal Data Form
Page**

+-------+--------+-------------------+---+--------+--------+--------+
| Pr    |        |                   |   |        |        |        |
| ogram |        |                   |   |        |        |        |
| Dir   |        |                   |   |        |        |        |
| ector |        |                   |   |        |        |        |
| /Prin |        |                   |   |        |        |        |
| cipal |        |                   |   |        |        |        |
| In    |        |                   |   |        |        |        |
| vesti |        |                   |   |        |        |        |
| gator |        |                   |   |        |        |        |
| (     |        |                   |   |        |        |        |
| Last, |        |                   |   |        |        |        |
| F     |        |                   |   |        |        |        |
| irst, |        |                   |   |        |        |        |
| Mid   |        |                   |   |        |        |        |
| dle): |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
|       |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| #     |        |                   |   |        |        |        |
| # Tar |        |                   |   |        |        |        |
| geted |        |                   |   |        |        |        |
| /Plan |        |                   |   |        |        |        |
| ned E |        |                   |   |        |        |        |
| nroll |        |                   |   |        |        |        |
| ment  |        |                   |   |        |        |        |
| Table |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| # Th  |        |                   |   |        |        |        |
| is re |        |                   |   |        |        |        |
| port  |        |                   |   |        |        |        |
| forma |        |                   |   |        |        |        |
| t sho |        |                   |   |        |        |        |
| uld N |        |                   |   |        |        |        |
| OT be |        |                   |   |        |        |        |
|  used |        |                   |   |        |        |        |
|  for  |        |                   |   |        |        |        |
| data  |        |                   |   |        |        |        |
| colle |        |                   |   |        |        |        |
| ction |        |                   |   |        |        |        |
|  from |        |                   |   |        |        |        |
|  stud |        |                   |   |        |        |        |
| y par |        |                   |   |        |        |        |
| ticip |        |                   |   |        |        |        |
| ants. |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| Study |        |                   |   |        |        |        |
| T     |        |                   |   |        |        |        |
| itle: |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| Total |        |                   |   |        |        |        |
| Pl    |        |                   |   |        |        |        |
| anned |        |                   |   |        |        |        |
| E     |        |                   |   |        |        |        |
| nroll |        |                   |   |        |        |        |
| ment: |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
|       |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| T     |        |                   |   |        |        |        |
| ARGET |        |                   |   |        |        |        |
| ED/PL |        |                   |   |        |        |        |
| ANNED |        |                   |   |        |        |        |
| E     |        |                   |   |        |        |        |
| NROLL |        |                   |   |        |        |        |
| MENT: |        |                   |   |        |        |        |
| N     |        |                   |   |        |        |        |
| umber |        |                   |   |        |        |        |
| of    |        |                   |   |        |        |        |
| Sub   |        |                   |   |        |        |        |
| jects |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| E     |        |                   |   | Sex/   |        |        |
| thnic |        |                   |   | Gender |        |        |
| Cat   |        |                   |   |        |        |        |
| egory |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
|       |        |                   |   | F      | Males  | Total  |
|       |        |                   |   | emales |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| His   |        |                   |   |        |        |        |
| panic |        |                   |   |        |        |        |
| or    |        |                   |   |        |        |        |
| L     |        |                   |   |        |        |        |
| atino |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| Not   |        |                   |   |        |        |        |
| His   |        |                   |   |        |        |        |
| panic |        |                   |   |        |        |        |
| or    |        |                   |   |        |        |        |
| L     |        |                   |   |        |        |        |
| atino |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| E     |        |                   |   |        |        |        |
| thnic |        |                   |   |        |        |        |
| Cate  |        |                   |   |        |        |        |
| gory: |        |                   |   |        |        |        |
| Total |        |                   |   |        |        |        |
| of    |        |                   |   |        |        |        |
| All   |        |                   |   |        |        |        |
| Sub   |        |                   |   |        |        |        |
| jects |        |                   |   |        |        |        |
| \*    |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| R     |        |                   |   |        |        |        |
| acial |        |                   |   |        |        |        |
| Categ |        |                   |   |        |        |        |
| ories |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| Ame   |        |                   |   |        |        |        |
| rican |        |                   |   |        |        |        |
| Ind   |        |                   |   |        |        |        |
| ian/A |        |                   |   |        |        |        |
| laska |        |                   |   |        |        |        |
| N     |        |                   |   |        |        |        |
| ative |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| Asian |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| N     |        |                   |   |        |        |        |
| ative |        |                   |   |        |        |        |
| Haw   |        |                   |   |        |        |        |
| aiian |        |                   |   |        |        |        |
| or    |        |                   |   |        |        |        |
| Other |        |                   |   |        |        |        |
| Pa    |        |                   |   |        |        |        |
| cific |        |                   |   |        |        |        |
| Isl   |        |                   |   |        |        |        |
| ander |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| Black |        |                   |   |        |        |        |
| or    |        |                   |   |        |        |        |
| Af    |        |                   |   |        |        |        |
| rican |        |                   |   |        |        |        |
| Ame   |        |                   |   |        |        |        |
| rican |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| White |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| R     |        |                   |   |        |        |        |
| acial |        |                   |   |        |        |        |
| C     |        |                   |   |        |        |        |
| atego |        |                   |   |        |        |        |
| ries: |        |                   |   |        |        |        |
| Total |        |                   |   |        |        |        |
| of    |        |                   |   |        |        |        |
| All   |        |                   |   |        |        |        |
| Sub   |        |                   |   |        |        |        |
| jects |        |                   |   |        |        |        |
| \*    |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+
| \*    |        |                   |   |        |        |        |
| The   |        |                   |   |        |        |        |
| "E    |        |                   |   |        |        |        |
| thnic |        |                   |   |        |        |        |
| Cate  |        |                   |   |        |        |        |
| gory: |        |                   |   |        |        |        |
| Total |        |                   |   |        |        |        |
| of    |        |                   |   |        |        |        |
| All   |        |                   |   |        |        |        |
| Subj  |        |                   |   |        |        |        |
| ects" |        |                   |   |        |        |        |
| must  |        |                   |   |        |        |        |
| be    |        |                   |   |        |        |        |
| equal |        |                   |   |        |        |        |
| to    |        |                   |   |        |        |        |
| the   |        |                   |   |        |        |        |
| "R    |        |                   |   |        |        |        |
| acial |        |                   |   |        |        |        |
| C     |        |                   |   |        |        |        |
| atego |        |                   |   |        |        |        |
| ries: |        |                   |   |        |        |        |
| Total |        |                   |   |        |        |        |
| of    |        |                   |   |        |        |        |
| All   |        |                   |   |        |        |        |
| Subje |        |                   |   |        |        |        |
| cts." |        |                   |   |        |        |        |
+-------+--------+-------------------+---+--------+--------+--------+

PHS 398/2590 (Rev. 11/07) Page [   ]{.underline} **Targeted/Planned
Enrollment Table Format Page**

<table style="width:100%;">
<colgroup>
<col style="width: 17%" />
<col style="width: 28%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 13%" />
<col style="width: 0%" />
<col style="width: 12%" />
<col style="width: 0%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">Program Director/Principal Investigator (Last, First,
Middle):</td>
<td colspan="12">     </td>
</tr>
<tr class="even">
<td colspan="15"><h2 id="inclusion-enrollment-report">Inclusion
Enrollment Report</h2></td>
</tr>
<tr class="odd">
<td colspan="15"><h1
id="this-report-format-should-not-be-used-for-data-collection-from-study-participants.-1">This
report format should NOT be used for data collection from study
participants.</h1></td>
</tr>
<tr class="even">
<td>Study Title:</td>
<td colspan="14">     </td>
</tr>
<tr class="odd">
<td>Total Enrollment:</td>
<td colspan="4">     </td>
<td colspan="3">Protocol Number:</td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td>Grant Number:</td>
<td colspan="3">     </td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td colspan="15">PART A. TOTAL ENROLLMENT REPORT: Number of Subjects
Enrolled to Date (Cumulative)<br />
by Ethnicity and Race</td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="2">Ethnic Category</td>
<td colspan="13">Sex/Gender</td>
</tr>
<tr class="even">
<td colspan="5">Females</td>
<td colspan="3">Males</td>
<td colspan="2">Unknown or Not Reported</td>
<td colspan="3">Total</td>
</tr>
<tr class="odd">
<td colspan="2">Hispanic or Latino</td>
<td colspan="5">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>**</td>
</tr>
<tr class="even">
<td colspan="2">Not Hispanic or Latino</td>
<td colspan="5">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Unknown (individuals not reporting ethnicity)</td>
<td colspan="5">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Ethnic Category: Total of All Subjects*</td>
<td colspan="5">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>*</td>
</tr>
<tr class="odd">
<td colspan="2">Racial Categories</td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="2">American Indian/Alaska Native</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Asian</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Native Hawaiian or Other Pacific Islander</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Black or African American</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">White</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">More Than One Race</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Unknown or Not Reported</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Racial Categories: Total of All Subjects*</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2">*</td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="15">PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics
or Latinos Enrolled to Date (Cumulative)</td>
</tr>
<tr class="even">
<td colspan="2">Racial Categories</td>
<td colspan="4">Females</td>
<td colspan="3">Males</td>
<td colspan="2">Unknown or Not Reported</td>
<td colspan="4">Total</td>
</tr>
<tr class="odd">
<td colspan="2">American Indian or Alaska Native</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Asian</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Native Hawaiian or Other Pacific Islander</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Black or African American</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">White</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">More Than One Race</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2">Unknown or Not Reported</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Racial Categories: Total of Hispanics or Latinos**</td>
<td colspan="4">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="2">**</td>
</tr>
<tr class="odd">
<td colspan="15"><p>* These totals must agree.</p>
<p>** These totals must agree.</p></td>
</tr>
</tbody>
</table>

PHS 398/2590 (Rev. 11/07) Page [   ]{.underline} **Inclusion Enrollment
Report Format Page**

+-----------+------+--------------------+----+-------------+---+-----+
| CDA TOC   |      | Candidate (Last,   |    |             |   |     |
| S         |      | first, middle):    |    |             |   |     |
| ubstitute |      |                    |    |             |   |     |
| Page      |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| Use this  |      |                    |    |             |   |     |
| Table of  |      |                    |    |             |   |     |
| Contents  |      |                    |    |             |   |     |
| for       |      |                    |    |             |   |     |
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| Career    |      |                    |    |             |   |     |
| De        |      |                    |    |             |   |     |
| velopment |      |                    |    |             |   |     |
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| page.     |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| RESEARCH  |      |                    |    |             |   |     |
| CAREER    |      |                    |    |             |   |     |
| DE        |      |                    |    |             |   |     |
| VELOPMENT |      |                    |    |             |   |     |
| AWARD     |      |                    |    |             |   |     |
| TABLE OF  |      |                    |    |             |   |     |
| CONTENTS  |      |                    |    |             |   |     |
| (S        |      |                    |    |             |   |     |
| ubstitute |      |                    |    |             |   |     |
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| Admin     |      |                    |    |             |   |     |
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+-----------+------+--------------------+----+-------------+---+-----+
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+-----------+------+--------------------+----+-------------+---+-----+
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| > 3       |      |                    |    |             |   |     |
| > pages)  |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 2\.     |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  Specific |      |                    |    |             |   |     |
| > Aims    |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 3\.     |      |                    |    |             |   |     |
| > B       |      |                    |    |             |   |     |
| ackground |      |                    |    |             |   |     |
| > and     |      |                    |    |             |   |     |
| > Sig     |      |                    |    |             |   |     |
| nificance |      |                    |    |             |   |     |
| > ....... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| > *(Items |      |                    |    |             |   |     |
| > 2-5     |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  included |      |                    |    |             |   |     |
| > in 25   |      |                    |    |             |   |     |
| > page    |      |                    |    |             |   |     |
| > limit)* |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 4\.     |      |                    |    |             |   |     |
| > Pr      |      |                    |    |             |   |     |
| eliminary |      |                    |    |             |   |     |
| > Studies |      |                    |    |             |   |     |
| /Progress |      |                    |    |             |   |     |
| > Report  |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 5\.     |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  Research |      |                    |    |             |   |     |
| > Design  |      |                    |    |             |   |     |
| > and     |      |                    |    |             |   |     |
| > Methods |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 6\.     |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
| Inclusion |      |                    |    |             |   |     |
| > E       |      |                    |    |             |   |     |
| nrollment |      |                    |    |             |   |     |
| > Report  |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  (Renewal |      |                    |    |             |   |     |
| > or      |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  Revision |      |                    |    |             |   |     |
| > App     |      |                    |    |             |   |     |
| lications |      |                    |    |             |   |     |
| > only)   |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 7\.     |      |                    |    |             |   |     |
| > Bib     |      |                    |    |             |   |     |
| liography |      |                    |    |             |   |     |
| > and     |      |                    |    |             |   |     |
| > R       |      |                    |    |             |   |     |
| eferences |      |                    |    |             |   |     |
| > Cited   |      |                    |    |             |   |     |
| /Progress |      |                    |    |             |   |     |
| > Report  |      |                    |    |             |   |     |
| > Pu      |      |                    |    |             |   |     |
| blication |      |                    |    |             |   |     |
| > List    |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 8\.     |      |                    |    |             |   |     |
| > P       |      |                    |    |             |   |     |
| rotection |      |                    |    |             |   |     |
| > of      |      |                    |    |             |   |     |
| > Human   |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  Subjects |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 9\.     |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
| Inclusion |      |                    |    |             |   |     |
| > of      |      |                    |    |             |   |     |
| > Women   |      |                    |    |             |   |     |
| > and     |      |                    |    |             |   |     |
| > Mi      |      |                    |    |             |   |     |
| norities. |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 10\.    |      |                    |    |             |   |     |
| > Targete |      |                    |    |             |   |     |
| d/Planned |      |                    |    |             |   |     |
| > E       |      |                    |    |             |   |     |
| nrollment |      |                    |    |             |   |     |
| > Table.  |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 11\.    |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
| Inclusion |      |                    |    |             |   |     |
| > of      |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  Children |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 12\.    |      |                    |    |             |   |     |
| > V       |      |                    |    |             |   |     |
| ertebrate |      |                    |    |             |   |     |
| > Animals |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 13\.    |      |                    |    |             |   |     |
| > Select  |      |                    |    |             |   |     |
| > Agents  |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 14\.    |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  Multiple |      |                    |    |             |   |     |
| > PD/PI   |      |                    |    |             |   |     |
| > L       |      |                    |    |             |   |     |
| eadership |      |                    |    |             |   |     |
| > Plan    |      |                    |    |             |   |     |
| > (Not    |      |                    |    |             |   |     |
| > ap      |      |                    |    |             |   |     |
| plicable. |      |                    |    |             |   |     |
| > Do not  |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
| include.) |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 15\.    |      |                    |    |             |   |     |
| > Cons    |      |                    |    |             |   |     |
| ortium/Co |      |                    |    |             |   |     |
| ntractual |      |                    |    |             |   |     |
| > Arran   |      |                    |    |             |   |     |
| gements\* |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 16\.    |      |                    |    |             |   |     |
| > Letters |      |                    |    |             |   |     |
| > of      |      |                    |    |             |   |     |
| > S       |      |                    |    |             |   |     |
| upport/Co |      |                    |    |             |   |     |
| nsultants |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| > 17\.    |      |                    |    |             |   |     |
| >         |      |                    |    |             |   |     |
|  Resource |      |                    |    |             |   |     |
| > Sharing |      |                    |    |             |   |     |
| > Plan(s) |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| Checklist |      |                    |    |             |   |     |
| ......    |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......... |      |                    |    |             |   |     |
| ......\.. |      |                    |    |             |   |     |
| .\...\... |      |                    |    |             |   |     |
| \...\...\ |      |                    |    |             |   |     |
| ...\...\. |      |                    |    |             |   |     |
| ..\...\.. |      |                    |    |             |   |     |
| .\...\... |      |                    |    |             |   |     |
| \...\...\ |      |                    |    |             |   |     |
| ...\...\. |      |                    |    |             |   |     |
| ..\...\.. |      |                    |    |             |   |     |
| .\...\... |      |                    |    |             |   |     |
| \...\...\ |      |                    |    |             |   |     |
| ...\...\. |      |                    |    |             |   |     |
| ..\...\.. |      |                    |    |             |   |     |
| .\...\... |      |                    |    |             |   |     |
| \...\.... |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| Appendix  |      |                    |    |             |   |     |
| (Five     |      |                    |    |             |   |     |
| identical |      |                    |    |             |   |     |
| CDs.)     |      |                    |    |             |   |     |
| Check if  |      |                    |    |             |   |     |
| Appendix  |      |                    |    |             |   |     |
| is        |      |                    |    |             |   |     |
| included  |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| *Note:    |      |                    |    |             |   |     |
| Font and  |      |                    |    |             |   |     |
| margin    |      |                    |    |             |   |     |
| req       |      |                    |    |             |   |     |
| uirements |      |                    |    |             |   |     |
| must      |      |                    |    |             |   |     |
| conform   |      |                    |    |             |   |     |
| to limits |      |                    |    |             |   |     |
| provided  |      |                    |    |             |   |     |
| in the    |      |                    |    |             |   |     |
| Specific  |      |                    |    |             |   |     |
| Instr     |      |                    |    |             |   |     |
| uctions*. |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| \*Include |      |                    |    |             |   |     |
| these     |      |                    |    |             |   |     |
| items     |      |                    |    |             |   |     |
| only when |      |                    |    |             |   |     |
| ap        |      |                    |    |             |   |     |
| plicable. |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| CI        |      |                    |    |             |   |     |
| TIZENSHIP |      |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+
| U.S.      |      |                    |    |             |   |     |
| citizen   | P    |                    |    | Non-citizen |   |     |
| or\       | erma |                    |    | with        |   |     |
| no        | nent |                    |    | temporary   |   |     |
| n-citizen | resi |                    |    | visa\       |   |     |
| national  | dent |                    |    | (Applicable |   |     |
|           | of   |                    |    | for only    |   |     |
|           | U.S. |                    |    | the K99     |   |     |
|           | (If  |                    |    | program)    |   |     |
|           | a    |                    |    |             |   |     |
|           | p    |                    |    |             |   |     |
|           | erma |                    |    |             |   |     |
|           | nent |                    |    |             |   |     |
|           | resi |                    |    |             |   |     |
|           | dent |                    |    |             |   |     |
|           | of   |                    |    |             |   |     |
|           | the  |                    |    |             |   |     |
|           | U    |                    |    |             |   |     |
|           | .S., |                    |    |             |   |     |
|           | a    |                    |    |             |   |     |
|           | n    |                    |    |             |   |     |
|           | otar |                    |    |             |   |     |
|           | ized |                    |    |             |   |     |
|           | s    |                    |    |             |   |     |
|           | tate |                    |    |             |   |     |
|           | ment |                    |    |             |   |     |
|           | must |                    |    |             |   |     |
|           | be   |                    |    |             |   |     |
|           | prov |                    |    |             |   |     |
|           | ided |                    |    |             |   |     |
|           | by   |                    |    |             |   |     |
|           | the  |                    |    |             |   |     |
|           | time |                    |    |             |   |     |
|           | of   |                    |    |             |   |     |
|           | awa  |                    |    |             |   |     |
|           | rd.) |                    |    |             |   |     |
+-----------+------+--------------------+----+-------------+---+-----+

PHS 398 (Rev. 11/07) Page [   ]{.underline} **CDA Substitute Form Page
3**

+---------------------------+-----+-----------------------+-----------+
| ## CAREER DEVELOPM        |     |                       |           |
| ENT AWARD REFERENCE REPOR |     |                       |           |
| T GUIDELINES *(Series K)* |     |                       |           |
+---------------------------+-----+-----------------------+-----------+
| Title of Award:           |     |                       |           |
|                           |     |                       |           |
|                           |     |                       |           |
+---------------------------+-----+-----------------------+-----------+
| Type of Award:            |     | Application           |           |
|                           |     | Submission Deadline:  |           |
|                           |     |                       |           |
+---------------------------+-----+-----------------------+-----------+
|                           |     |                       |           |
+---------------------------+-----+-----------------------+-----------+
| Name of Candidate (Last,  |     |                       |           |
| first, middle):           |     |                       |           |
+---------------------------+-----+-----------------------+-----------+
| Name of Respondent (Last, |     |                       |           |
| first, middle):           |     |                       |           |
+---------------------------+-----+-----------------------+-----------+
| The candidate is applying |     |                       |           |
| to the National           |     |                       |           |
| Institutes of Health for  |     |                       |           |
| a Career Development      |     |                       |           |
| Award (CDA). The purpose  |     |                       |           |
| of this award is to       |     |                       |           |
| develop the research      |     |                       |           |
| capabilities and career   |     |                       |           |
| of the applicant. These   |     |                       |           |
| awards provide up to five |     |                       |           |
| years of salary support   |     |                       |           |
| and guarantee them the    |     |                       |           |
| ability to devote at      |     |                       |           |
| least 75 percent of their |     |                       |           |
| time to research for the  |     |                       |           |
| duration of the award,    |     |                       |           |
| depending on the specific |     |                       |           |
| program for which the     |     |                       |           |
| candidate is applying.    |     |                       |           |
| Many of these awards also |     |                       |           |
| provide funds for         |     |                       |           |
| research and career       |     |                       |           |
| development costs. The    |     |                       |           |
| award is available to     |     |                       |           |
| persons who have          |     |                       |           |
| demonstrated considerable |     |                       |           |
| potential to become       |     |                       |           |
| independent researchers,  |     |                       |           |
| but who need additional   |     |                       |           |
| supervised research       |     |                       |           |
| experience in a           |     |                       |           |
| productive scientific     |     |                       |           |
| setting.                  |     |                       |           |
|                           |     |                       |           |
| We would appreciate       |     |                       |           |
| receiving your evaluation |     |                       |           |
| of the above candidate    |     |                       |           |
| with special reference    |     |                       |           |
| to:                       |     |                       |           |
|                           |     |                       |           |
| -   potential for         |     |                       |           |
|     conducting research;  |     |                       |           |
|                           |     |                       |           |
| -   evidence of           |     |                       |           |
|     originality;          |     |                       |           |
|                           |     |                       |           |
| -   adequacy of           |     |                       |           |
|     scientific            |     |                       |           |
|     background;           |     |                       |           |
|                           |     |                       |           |
| -   quality of research   |     |                       |           |
|     endeavors or          |     |                       |           |
|     publications to date, |     |                       |           |
|     if any;               |     |                       |           |
|                           |     |                       |           |
| -   commitment to         |     |                       |           |
|     health-oriented       |     |                       |           |
|     research; and         |     |                       |           |
|                           |     |                       |           |
| -   need for further      |     |                       |           |
|     research experience   |     |                       |           |
|     and training.         |     |                       |           |
|                           |     |                       |           |
| Any related comments that |     |                       |           |
| you may wish to provide   |     |                       |           |
| would be welcomed. These  |     |                       |           |
| references will be used   |     |                       |           |
| by PHS committees of      |     |                       |           |
| consultants in assessing  |     |                       |           |
| candidates.               |     |                       |           |
|                           |     |                       |           |
| Complete the report in    |     |                       |           |
| English on 8-1/2 x 11\"   |     |                       |           |
| sheets of paper. Return   |     |                       |           |
| your reference report to  |     |                       |           |
| the candidate sealed in   |     |                       |           |
| the envelope as soon as   |     |                       |           |
| possible and in           |     |                       |           |
| sufficient time so that   |     |                       |           |
| the candidate can meet    |     |                       |           |
| the application           |     |                       |           |
| submission deadline.      |     |                       |           |
| References must be        |     |                       |           |
| submitted with the        |     |                       |           |
| application.              |     |                       |           |
|                           |     |                       |           |
| We have asked the         |     |                       |           |
| candidate to provide you  |     |                       |           |
| with a self-addressed     |     |                       |           |
| envelope with the         |     |                       |           |
| following words in the    |     |                       |           |
| front bottom corner: "DO  |     |                       |           |
| NOT OPEN---PHS USE ONLY." |     |                       |           |
| Candidates are not to     |     |                       |           |
| open the references.      |     |                       |           |
| Under the Privacy Act of  |     |                       |           |
| 1974, CDA candidates may  |     |                       |           |
| request personal          |     |                       |           |
| information contained in  |     |                       |           |
| their records, including  |     |                       |           |
| this reference. Thank you |     |                       |           |
| for your assistance.      |     |                       |           |
+---------------------------+-----+-----------------------+-----------+

PHS 398 (Rev. 11/07) SAMPLE **CDA Reference Guidelines Format Page**

+----------------+-----------------------+----------------+---+---+---+----+
| Institutional  | Program               |                |   |   |   |    |
| Training TOC   | Director/Principal    |                |   |   |   |    |
| Substitute     | Investigator\         |                |   |   |   |    |
| Page           | (Last, first,         |                |   |   |   |    |
|                | middle):              |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Type the name  |                       |                |   |   |   |    |
| of the program |                       |                |   |   |   |    |
| dire           |                       |                |   |   |   |    |
| ctor/principal |                       |                |   |   |   |    |
| investigator   |                       |                |   |   |   |    |
| at the top of  |                       |                |   |   |   |    |
| each printed   |                       |                |   |   |   |    |
| page and each  |                       |                |   |   |   |    |
| continuation   |                       |                |   |   |   |    |
| page. (For     |                       |                |   |   |   |    |
| type           |                       |                |   |   |   |    |
| s              |                       |                |   |   |   |    |
| pecifications, |                       |                |   |   |   |    |
| see PHS 398    |                       |                |   |   |   |    |
| Instructions.) |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| INSTITUTIONAL  |                       |                |   |   |   |    |
| RESEARCH       |                       |                |   |   |   |    |
| TRAINING\      |                       |                |   |   |   |    |
| INCLUDING RUTH |                       |                |   |   |   |    |
| L. KIRSCHSTEIN |                       |                |   |   |   |    |
| NATIONAL       |                       |                |   |   |   |    |
| RESEARCH       |                       |                |   |   |   |    |
| SERVICE AWARD  |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
| TABLE OF       |                       |                |   |   |   |    |
| CONTENTS       |                       |                |   |   |   |    |
| (Substitute    |                       |                |   |   |   |    |
| Page)          |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
|                |                       |                |   | * |   |    |
|                |                       |                |   | P |   |    |
|                |                       |                |   | a |   |    |
|                |                       |                |   | g |   |    |
|                |                       |                |   | e |   |    |
|                |                       |                |   | N |   |    |
|                |                       |                |   | u |   |    |
|                |                       |                |   | m |   |    |
|                |                       |                |   | b |   |    |
|                |                       |                |   | e |   |    |
|                |                       |                |   | r |   |    |
|                |                       |                |   | s |   |    |
|                |                       |                |   | * |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Face Page      |                       |                |   |   |   | 1  |
| (*Form Page    |                       |                |   |   |   |    |
| 1*)            |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Description,   |                       |                |   |   |   | 2  |
| Proje          |                       |                |   |   |   |    |
| ct/Performance |                       |                |   |   |   |    |
| Sites,         |                       |                |   |   |   |    |
| Senior/Key     |                       |                |   |   |   |    |
| Personnel,     |                       |                |   |   |   |    |
| Other          |                       |                |   |   |   |    |
| Significant    |                       |                |   |   |   |    |
| Contributors,  |                       |                |   |   |   |    |
| and Human      |                       |                |   |   |   |    |
| Embryonic Stem |                       |                |   |   |   |    |
| Cells (*Form   |                       |                |   |   |   |    |
| Page 2, Form   |                       |                |   |   |   |    |
| Page           |                       |                |   |   |   |    |
| 2-continued,   |                       |                |   |   |   |    |
| and additional |                       |                |   |   |   |    |
| continuation   |                       |                |   |   |   |    |
| page, if       |                       |                |   |   |   |    |
| necessary*)    |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Table of       |                       |                |   |   |   |    |
| Contents       |                       |                |   |   |   |    |
| (*this         |                       |                |   |   |   |    |
| Institutional  |                       |                |   |   |   |    |
| Training       |                       |                |   |   |   |    |
| Substitute     |                       |                |   |   |   |    |
| Form Page 3*)  |                       |                |   |   |   |    |
| ............   |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Detailed       |                       |                |   |   |   |    |
| Budget for     |                       |                |   |   |   |    |
| Initial Budget |                       |                |   |   |   |    |
| Period         |                       |                |   |   |   |    |
| *              |                       |                |   |   |   |    |
| (Institutional |                       |                |   |   |   |    |
| Training       |                       |                |   |   |   |    |
| Substitute     |                       |                |   |   |   |    |
| Form Page 4)*  |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Budget for     |                       |                |   |   |   |    |
| Entire         |                       |                |   |   |   |    |
| Proposed       |                       |                |   |   |   |    |
| Period of      |                       |                |   |   |   |    |
| Support        |                       |                |   |   |   |    |
| *              |                       |                |   |   |   |    |
| (Institutional |                       |                |   |   |   |    |
| Training       |                       |                |   |   |   |    |
| Substitute     |                       |                |   |   |   |    |
| Form Page 5)*  |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Biographical   |                       |                |   |   |   |    |
| Sketch---      |                       |                |   |   |   |    |
| Program        |                       |                |   |   |   |    |
| Dire           |                       |                |   |   |   |    |
| ctor/Principal |                       |                |   |   |   |    |
| Investigator   |                       |                |   |   |   |    |
| *(Not to       |                       |                |   |   |   |    |
| exceed four    |                       |                |   |   |   |    |
| pages)*        |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Resources      |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Research       |                       |                |   |   |   |    |
| Training       |                       |                |   |   |   |    |
| Program Plan   |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 1\.            |                       |                |   |   |   |    |
| Introduction   |                       |                |   |   |   |    |
| (Resubmission  |                       |                |   |   |   |    |
| or Revision    |                       |                |   |   |   |    |
| Application    |                       |                |   |   |   |    |
| only)          |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 2\. Background |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 3\. Program    |                       |                |   |   |   |    |
| Plan           |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| a\. Program    |                       |                |   |   |   |    |
| Administration |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| b\. Program    |                       |                |   |   |   |    |
| Faculty        |                       |                |   |   |   |    |
| \.             |                       |                |   |   |   |    |
| ..\...\...\... |                       |                |   |   |   |    |
| \...\...\...\. |                       |                |   |   |   |    |
| ..\........... |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .......*(Items |                       |                |   |   |   |    |
| 2-5: not to    |                       |                |   |   |   |    |
| exceed 25      |                       |                |   |   |   |    |
| pages,*        |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| c\. Proposed   |                       |                |   |   |   |    |
| Training       |                       |                |   |   |   |    |
| \...\...       |                       |                |   |   |   |    |
| \...\...\...\. |                       |                |   |   |   |    |
| ..\...\...\... |                       |                |   |   |   |    |
| \...\...\..... |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| ....*excluding |                       |                |   |   |   |    |
| tables\*)*     |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| d\. Training   |                       |                |   |   |   |    |
| Program        |                       |                |   |   |   |    |
| Evaluation     |                       |                |   |   |   |    |
| ...            |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| e\. Trainee    |                       |                |   |   |   |    |
| Candidates     |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 4\.            |                       |                |   |   |   |    |
| Recruitment    |                       |                |   |   |   |    |
| and Retention  |                       |                |   |   |   |    |
| Plan to        |                       |                |   |   |   |    |
| Enhance        |                       |                |   |   |   |    |
| Diversity .    |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 5\. Plan for   |                       |                |   |   |   |    |
| Instruction in |                       |                |   |   |   |    |
| the            |                       |                |   |   |   |    |
| Responsible    |                       |                |   |   |   |    |
| Conduct of     |                       |                |   |   |   |    |
| Research       |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 6\. Progress   |                       |                |   |   |   |    |
| Report         |                       |                |   |   |   |    |
| (Renewal       |                       |                |   |   |   |    |
| Applications   |                       |                |   |   |   |    |
| Only)          |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 7\. Human      |                       |                |   |   |   |    |
| Subjects       |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 8\. Vertebrate |                       |                |   |   |   |    |
| Animals        |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 9\. Select     |                       |                |   |   |   |    |
| Agent Research |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 10\.           |                       |                |   |   |   |    |
| Literature     |                       |                |   |   |   |    |
| Cited          |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 11\. Multiple  |                       |                |   |   |   |    |
| PD Leadership  |                       |                |   |   |   |    |
| Plan (if       |                       |                |   |   |   |    |
| applicable)    |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 12\.           |                       |                |   |   |   |    |
| Consorti       |                       |                |   |   |   |    |
| um/Contractual |                       |                |   |   |   |    |
| Arrangements   |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 13\.           |                       |                |   |   |   |    |
| Participating  |                       |                |   |   |   |    |
| Faculty        |                       |                |   |   |   |    |
| Biosketches    |                       |                |   |   |   |    |
| (not to exceed |                       |                |   |   |   |    |
| four pages     |                       |                |   |   |   |    |
| each)          |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 14\. Data      |                       |                |   |   |   |    |
| Tables         |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| 15\. Letters   |                       |                |   |   |   |    |
| of Support     |                       |                |   |   |   |    |
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Checklist      |                       |                |   |   |   |    |
| ..........     |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
| .............. |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
| Appendix       |                       |                |   |   | C |    |
| *(Five         |                       |                |   |   | h |    |
| identical      |                       |                |   |   | e |    |
| CDs.)*         |                       |                |   |   | c |    |
|                |                       |                |   |   | k |    |
|                |                       |                |   |   | i |    |
|                |                       |                |   |   | f |    |
|                |                       |                |   |   | \ |    |
|                |                       |                |   |   | A |    |
|                |                       |                |   |   | p |    |
|                |                       |                |   |   | p |    |
|                |                       |                |   |   | e |    |
|                |                       |                |   |   | n |    |
|                |                       |                |   |   | d |    |
|                |                       |                |   |   | i |    |
|                |                       |                |   |   | x |    |
|                |                       |                |   |   | i |    |
|                |                       |                |   |   | s |    |
|                |                       |                |   |   | \ |    |
|                |                       |                |   |   | i |    |
|                |                       |                |   |   | n |    |
|                |                       |                |   |   | c |    |
|                |                       |                |   |   | l |    |
|                |                       |                |   |   | u |    |
|                |                       |                |   |   | d |    |
|                |                       |                |   |   | e |    |
|                |                       |                |   |   | d |    |
+----------------+-----------------------+----------------+---+---+---+----+
| \* Font and    |                       |                |   |   |   |    |
| margin         |                       |                |   |   |   |    |
| requirements   |                       |                |   |   |   |    |
| must conform   |                       |                |   |   |   |    |
| to limits      |                       |                |   |   |   |    |
| provided in    |                       |                |   |   |   |    |
| PHS 398        |                       |                |   |   |   |    |
| Specific       |                       |                |   |   |   |    |
| Instructions.  |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+
|                |                       |                |   |   |   |    |
+----------------+-----------------------+----------------+---+---+---+----+

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Institutional Training
Substitute Form Page 3**

+--------------------+---------------------+---+-------+---+---+-----------+
| Institutional      | Program             |   |       |   |   |           |
| Training Initial   | Director/Principal  |   |       |   |   |           |
| Budget Period      | Investigator:[\     |   |       |   |   |           |
| Substitute Page    | ]{.underline}(Last, |   |       |   |   |           |
|                    | first, middle)      |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| DETAILED BUDGET    |                     |   | FROM  |   |   | THROUGH   |
| FOR INITIAL BUDGET |                     |   |       |   |   |           |
| PERIOD\            |                     |   |       |   |   |           |
| DIRECT COSTS ONLY  |                     |   |       |   |   |           |
| (Institutional     |                     |   |       |   |   |           |
| Training           |                     |   |       |   |   |           |
| Substitute Page)   |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| STIPENDS           |                     |   |       |   |   | DOLLAR    |
|                    |                     |   |       |   |   | TOTAL     |
+--------------------+---------------------+---+-------+---+---+-----------+
| PREDOCTORAL        |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| No. Requested:     |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| POSTDOCTORAL       |                     |   |       |   |   |           |
| *(Itemize)*        |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| No. Requested:     |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| OTHER *(Specify)*  |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| No. Requested:     |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| TOTAL STIPENDS     |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| TUITION and FEES   |                     |   |       |   |   |           |
| *(Itemize)*        |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| TRAINEE TRAVEL     |                     |   |       |   |   |           |
| *(Describe)*       |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| TRAINING-RELATED   |                     |   |       |   |   |           |
| EXPENSES           |                     |   |       |   |   |           |
| (including Health  |                     |   |       |   |   |           |
| Insurance)         |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+
| TOTAL DIRECT COSTS |                     |   |       |   | * |           |
| FOR INITIAL BUDGET |                     |   |       |   | * |           |
| PERIOD *(Also      |                     |   |       |   | \ |           |
| enter on Face      |                     |   |       |   | $ |           |
| Page, Item 7)*     |                     |   |       |   | * |           |
|                    |                     |   |       |   | * |           |
+--------------------+---------------------+---+-------+---+---+-----------+
|                    |                     |   |       |   |   |           |
+--------------------+---------------------+---+-------+---+---+-----------+

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Institutional Training
Substitute Form Page 4**

<table>
<colgroup>
<col style="width: 22%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">Institutional Training Entire Budget Period Substitute
Page</td>
<td colspan="5">Program Director/Principal Investigator:<br />
(Last, first, middle)</td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="15">BUDGET FOR ENTIRE PROPOSED PERIOD OF SUPPORT<br />
DIRECT COSTS ONLY (Institutional Training Substitute Page)</td>
</tr>
<tr class="odd">
<td>BUDGET CATEGORY</td>
<td colspan="3">INITIAL BUDGET<br />
PERIOD</td>
<td colspan="11">ADDITIONAL YEARS OF SUPPORT REQUESTED</td>
</tr>
<tr class="even">
<td>TOTALS</td>
<td colspan="3"><em>(from Form Page 4)</em></td>
<td colspan="2">2nd</td>
<td colspan="3">3rd</td>
<td colspan="4">4th</td>
<td colspan="2">5th</td>
</tr>
<tr class="odd">
<td>PREDOCTORAL STIPENDS</td>
<td><p>No.</p>
<p>   </p></td>
<td colspan="2">     </td>
<td><p>No.</p>
<p>   </p></td>
<td>     </td>
<td><p>No.</p>
<p>   </p></td>
<td colspan="2">     </td>
<td><p>No.</p>
<p>   </p></td>
<td colspan="3">     </td>
<td><p>No.</p>
<p>   </p></td>
<td>     </td>
</tr>
<tr class="even">
<td>POSTDOCTORAL STIPENDS</td>
<td>   </td>
<td colspan="2">     </td>
<td>   </td>
<td>     </td>
<td>   </td>
<td colspan="2">     </td>
<td>   </td>
<td colspan="3">     </td>
<td>   </td>
<td>     </td>
</tr>
<tr class="odd">
<td>OTHER STIPENDS</td>
<td>   </td>
<td colspan="2">     </td>
<td>   </td>
<td>     </td>
<td>   </td>
<td colspan="2">     </td>
<td>   </td>
<td colspan="3">     </td>
<td>   </td>
<td>     </td>
</tr>
<tr class="even">
<td>TOTAL STIPENDS</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>TUITION AND FEES</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>TRAINEE TRAVEL</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td>TRAINING-RELATED EXPENSES (including Health Insurance)</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td>TOTAL DIRECT COSTS</td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="11">TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD
<em>(Item 8a, Face Page)</em></td>
<td><strong>$</strong></td>
<td colspan="3">     </td>
</tr>
<tr class="even">
<td colspan="15"><p>JUSTIFICATION. For all years, explain the basis for
the budget categories requested. Follow the instructions for the Initial
Budget Period and include anticipated postdoctoral levels.</p>
<p>     </p></td>
</tr>
</tbody>
</table>

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Institutional Training
Substitute Form Page 5**

+------------------------+-----+---+---+-------------------+---+---+---+
| Program                |     |   |   |                   |   |   |   |
| Director/Principal     |     |   |   |                   |   |   |   |
| Investigator (Last,    |     |   |   |                   |   |   |   |
| First, Middle):        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
| # DO NOT S             |     |   |   |                   |   |   |   |
| UBMIT UNLESS REQUESTED |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
| Renewal Applications   |     |   |   |                   |   |   |   |
| Only                   |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
| # SENIO                |     |   |   |                   |   |   |   |
| R/KEY PERSONNEL REPORT |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
| All Senior/Key         |     |   |   |                   |   |   |   |
| Personnel for the      |     |   |   |                   |   |   |   |
| Current Budget Period  |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
| Name                   | Deg | S |   | Role on Project\  | M |   |   |
|                        | ree | S |   | (e.g. PI, Res.    | o |   |   |
|                        | (s) | N |   | Assoc.)           | n |   |   |
|                        |     | ( |   |                   | t |   |   |
|                        |     | l |   |                   | h |   |   |
|                        |     | a |   |                   | s |   |   |
|                        |     | s |   |                   | D |   |   |
|                        |     | t |   |                   | e |   |   |
|                        |     | 4 |   |                   | v |   |   |
|                        |     | d |   |                   | o |   |   |
|                        |     | i |   |                   | t |   |   |
|                        |     | g |   |                   | e |   |   |
|                        |     | i |   |                   | d |   |   |
|                        |     | t |   |                   | t |   |   |
|                        |     | s |   |                   | o |   |   |
|                        |     | ) |   |                   | P |   |   |
|                        |     |   |   |                   | r |   |   |
|                        |     |   |   |                   | o |   |   |
|                        |     |   |   |                   | j |   |   |
|                        |     |   |   |                   | e |   |   |
|                        |     |   |   |                   | c |   |   |
|                        |     |   |   |                   | t |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   | C | A | S |
|                        |     |   |   |                   | a | c | u |
|                        |     |   |   |                   | l | a | m |
|                        |     |   |   |                   |   | d | m |
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|                        |     |   |   |                   |   |   | r |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
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|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
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|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
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|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+
|                        |     |   |   |                   |   |   |   |
+------------------------+-----+---+---+-------------------+---+---+---+

PHS 398 (Rev. 11/07) Page [   ]{.underline} **Senior/Key Personnel
Report Format Page**

***Mailing address for application***

*Use this label or a facsimile*

**[All applications and other deliveries to the Center for Scientific
Review must come either via courier delivery or via the United States
Postal Service (USPS.) Applications delivered by individuals to the
Center for Scientific Review will not be accepted.]{.underline}**

**Applications sent via the USPS EXPRESS or REGULAR MAIL should be sent
to the following address:**

+-----------------------------------------------------------------------+
| **CENTER FOR SCIENTIFIC REVIEW**                                      |
|                                                                       |
| **NATIONAL INSTITUTES OF HEALTH**                                     |
|                                                                       |
| **6701 ROCKLEDGE DRIVE**                                              |
|                                                                       |
| **ROOM 1040 -- MSC 7710**                                             |
|                                                                       |
| **BETHESDA, MD 20892-7710**                                           |
+-----------------------------------------------------------------------+

**NOTE: All applications sent via a courier delivery service (non-USPS)
should use this address, but [CHANGE THE ZIP CODE TO
20817]{.underline}**

**The telephone number is 301-435-0715. C.O.D. applications will
*[not]{.underline}* be accepted.**

**A special label for responding to RFAs is not required.**