+-----+--------------------------------------------------+-------------+
|     |                                                  |             |
+-----+--------------------------------------------------+-------------+
|     | > Applicant's Instructions for                   |             |
|     | >                                                |             |
|     | > Submission of References                       |             |
+-----+--------------------------------------------------+-------------+
|     | > This notice explains the submission of         |             |
|     | > references for\                                |             |
|     | > Ruth L. Kirschstein National Research Service  |             |
|     | > Award Individual Fellowship applicants.        |             |
|     | > Applications will not be reviewed unless at    |             |
|     | > least three (3) references are received with   |             |
|     | > the application. Applicants are responsible    |             |
|     | > for complete applications reaching the PHS on  |             |
|     | > schedule.                                      |             |
+-----+--------------------------------------------------+-------------+
|     | > Submission Process                             |             |
+-----+--------------------------------------------------+-------------+
|     | > Forward reference forms to referees with       |             |
|     | > sufficient lead time so that the completed     |             |
|     | > forms will be part of the application package. |             |
|     | > Fill out upper right corner before forwarding  |             |
|     | > to referee. Referees should be provided with   |             |
|     | > postage-paid return envelopes addressed to you |             |
|     | > with the following words in the front bottom   |             |
|     | > left corner ---DO NOT OPEN---PHS USE ONLY.     |             |
|     | > Attach unopened references to the front of the |             |
|     | > original application and submit the entire     |             |
|     | > package by the submission deadline.            |             |
+-----+--------------------------------------------------+-------------+
|     |                                                  |             |
+-----+--------------------------------------------------+-------------+

+--------+---------------------------------------------------+---------+
|        |                                                   |         |
+--------+---------------------------------------------------+---------+
|        | > **Note to Respondent**                          |         |
+--------+---------------------------------------------------+---------+
|        | > The applicant is applying for a competitive     |         |
|        | > Ruth L. Kirschstein National Research Service   |         |
|        | > Award Individual Fellowship from the Public     |         |
|        | > Health Service (PHS) for research training in   |         |
|        | > health-related areas. Your assessment of the    |         |
|        | > applicant's potential for a research career is  |         |
|        | > requested. The references will be used by PHS   |         |
|        | > committees of consultants in assessing          |         |
|        | > applicants.                                     |         |
+--------+---------------------------------------------------+---------+
|        |                                                   |         |
+--------+---------------------------------------------------+---------+
|        | > At least three references must be submitted     |         |
|        | > with the application or the application will be |         |
|        | > returned. ***Please complete this form and      |         |
|        | > return it to the applicant in sufficient time   |         |
|        | > for the applicant to meet the deadline date.*** |         |
+--------+---------------------------------------------------+---------+
|        |                                                   |         |
+--------+---------------------------------------------------+---------+
|        | > Complete the form in English. The form should   |         |
|        | > be typed if possible. If any part of the form   |         |
|        | > is handwritten, use a black pen. The color blue |         |
|        | > does not reproduce. If the space provided is    |         |
|        | > inadequate, use an 8-1/2 x 11" sheet of paper   |         |
|        | > and put the applicant's name in the upper right |         |
|        | > corner.                                         |         |
+--------+---------------------------------------------------+---------+
|        |                                                   |         |
+--------+---------------------------------------------------+---------+
|        | > Although the Privacy Act of 1974 allows NSRA    |         |
|        | > applicants to have access to personal           |         |
|        | > information contained in their records, we have |         |
|        | > asked the applicant to provide you with a       |         |
|        | > self-addressed envelope with --- *DO NOT        |         |
|        | > OPEN---PHS USE ONLY* --- in the front bottom    |         |
|        | > left corner. Applicants are asked not to open   |         |
|        | > the references in order to protect the          |         |
|        | > confidentiality of the process. Thank you for   |         |
|        | > your assistance.                                |         |
+--------+---------------------------------------------------+---------+
|        |                                                   |         |
+--------+---------------------------------------------------+---------+

> PHS estimates that it will take 45 minutes to complete this form. This
> includes time for reviewing the instructions, gathering needed
> information, and completing the form. An agency may not conduct or
> sponsor, and a person is not required to respond to, a collection of
> information unless it displays a currently valid OMB control number.
> If you have comments regarding this burden estimate or any other
> aspects of the collection of information, including suggestions for
> reducing this burden, send comments to NIH Project Clearance Office,
> 6705 Rockledge Drive MSC 7974, Bethesda, MD 20892-7974, Attention: PRA
> (0925-0002). ***DO NOT RETURN THE COMPLETED FORM TO THIS ADDRESS*.**

+---------------------+------------+---+---+----------------------+---------+
| Form Approved       |            |   |   |                      |         |
| Through 09/30/2011  |            |   |   |                      |         |
| OMB No. 0925-0002   |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| Department of       |            |   |   | **(Applicant         |         |
| Health and Human    |            |   |   | completes this       |         |
| Services\           |            |   |   | block.)**            |         |
| Public Health       |            |   |   |                      |         |
| Service             |            |   |   |                      |         |
|                     |            |   |   |                      |         |
| ## Reference        |            |   |   |                      |         |
|                     |            |   |   |                      |         |
| # Ruth L. Kirschst  |            |   |   |                      |         |
| ein National Resear |            |   |   |                      |         |
| ch Service Award In |            |   |   |                      |         |
| dividual Fellowship |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
|                     |            |   |   | NAME OF APPLICANT    |         |
|                     |            |   |   | *(Last, first,       |         |
|                     |            |   |   | middle initial)*     |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
|                     |            |   |   | PROPOSED SPONSORING  |         |
|                     |            |   |   | INSTITUTION          |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| Compare the         |            |   |   |                      |         |
| applicant with      |            |   |   |                      |         |
| other individuals   |            |   |   |                      |         |
| of similar training |            |   |   |                      |         |
| and experience with |            |   |   |                      |         |
| whom you have been  |            |   |   |                      |         |
| associated. Use the |            |   |   |                      |         |
| following numerical |            |   |   |                      |         |
| scores, from 1      |            |   |   |                      |         |
| (best) to 5         |            |   |   |                      |         |
| (poorest). Mark     |            |   |   |                      |         |
| every block; insert |            |   |   |                      |         |
| "X" if insufficient |            |   |   |                      |         |
| knowledge to rate   |            |   |   |                      |         |
| and "NA" if not     |            |   |   |                      |         |
| applicable.         |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| **1** Comparable to |            |   |   |                      |         |
| the best individual |            |   |   |                      |         |
| in a current class  |            |   |   |                      |         |
| or research         |            |   |   |                      |         |
| laboratory (upper   |            |   |   |                      |         |
| 5%)                 |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| **2** Upper 6 to    |            | * |   |                      |         |
| 20%                 |            | * |   |                      |         |
|                     |            | 4 |   |                      |         |
|                     |            | * |   |                      |         |
|                     |            | * |   |                      |         |
|                     |            | M |   |                      |         |
|                     |            | i |   |                      |         |
|                     |            | d |   |                      |         |
|                     |            | d |   |                      |         |
|                     |            | l |   |                      |         |
|                     |            | e |   |                      |         |
|                     |            | 4 |   |                      |         |
|                     |            | 1 |   |                      |         |
|                     |            | t |   |                      |         |
|                     |            | o |   |                      |         |
|                     |            | 6 |   |                      |         |
|                     |            | 0 |   |                      |         |
|                     |            | % |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| **3** Upper 21 to   |            | * |   |                      |         |
| 40%                 |            | * |   |                      |         |
|                     |            | 5 |   |                      |         |
|                     |            | * |   |                      |         |
|                     |            | * |   |                      |         |
|                     |            | L |   |                      |         |
|                     |            | o |   |                      |         |
|                     |            | w |   |                      |         |
|                     |            | e |   |                      |         |
|                     |            | r |   |                      |         |
|                     |            | 4 |   |                      |         |
|                     |            | 0 |   |                      |         |
|                     |            | % |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| ***Use black        |            |   |   |                      |         |
| ink.***             |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
|    Research Ability |            |   |   |    Originality       |         |
| and Potential       |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
|    Written and      |            |   |   |    Accuracy          |         |
| Verbal              |            |   |   |                      |         |
| Communications      |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
|    Perseverance in  |            |   |   |    Scientific        |         |
| Pursuing Goals      |            |   |   | Background           |         |
+---------------------+------------+---+---+----------------------+---------+
|    Self-Reliance    |            |   |   |    Familiarity with  |         |
| and Independence    |            |   |   | Research Literature  |         |
+---------------------+------------+---+---+----------------------+---------+
|    Clinical         |            |   |   |    Ability to        |         |
| Proficiency, if     |            |   |   | Organize Scientific  |         |
| relevant            |            |   |   | Data                 |         |
+---------------------+------------+---+---+----------------------+---------+
|    Laboratory       |            |   |   |                      |         |
| Skills and          |            |   |   |                      |         |
| Techniques, if      |            |   |   |                      |         |
| relevant            |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| Describe your       |            |   |   |                      |         |
| association with    |            |   |   |                      |         |
| the applicant.      |            |   |   |                      |         |
| Comment on the      |            |   |   |                      |         |
| above items,        |            |   |   |                      |         |
| including other     |            |   |   |                      |         |
| areas as            |            |   |   |                      |         |
| appropriate,        |            |   |   |                      |         |
| identifying the     |            |   |   |                      |         |
| strengths and       |            |   |   |                      |         |
| weaknesses that     |            |   |   |                      |         |
| should be           |            |   |   |                      |         |
| considered in       |            |   |   |                      |         |
| evaluating the      |            |   |   |                      |         |
| applicant's         |            |   |   |                      |         |
| potential for a     |            |   |   |                      |         |
| research career.    |            |   |   |                      |         |
| *(Use continuation  |            |   |   |                      |         |
| pages as            |            |   |   |                      |         |
| necessary.)*        |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| DATES ASSOCIATED    |            |   | C |                      |         |
| WITH APPLICANT      |            |   | A |                      |         |
|                     |            |   | P |                      |         |
|                     |            |   | A |                      |         |
|                     |            |   | C |                      |         |
|                     |            |   | I |                      |         |
|                     |            |   | T |                      |         |
|                     |            |   | Y |                      |         |
|                     |            |   | A |                      |         |
|                     |            |   | T |                      |         |
|                     |            |   | T |                      |         |
|                     |            |   | H |                      |         |
|                     |            |   | A |                      |         |
|                     |            |   | T |                      |         |
|                     |            |   | T |                      |         |
|                     |            |   | I |                      |         |
|                     |            |   | M |                      |         |
|                     |            |   | E |                      |         |
|                     |            |   | * |                      |         |
|                     |            |   | ( |                      |         |
|                     |            |   | T |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | c |                      |         |
|                     |            |   | h |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | , |                      |         |
|                     |            |   | d |                      |         |
|                     |            |   | i |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | t |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | t |                      |         |
|                     |            |   | i |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | n |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | d |                      |         |
|                     |            |   | v |                      |         |
|                     |            |   | i |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | , |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | u |                      |         |
|                     |            |   | p |                      |         |
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|                     |            |   | v |                      |         |
|                     |            |   | i |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | , |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | r |                      |         |
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|                     |            |   | t |                      |         |
|                     |            |   | h |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | ) |                      |         |
|                     |            |   | ( |                      |         |
|                     |            |   | U |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | e |                      |         |
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|                     |            |   | n |                      |         |
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|                     |            |   | u |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | t |                      |         |
|                     |            |   | i |                      |         |
|                     |            |   | o |                      |         |
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|                     |            |   | p |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | g |                      |         |
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|                     |            |   | e |                      |         |
|                     |            |   | s |                      |         |
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|                     |            |   | a |                      |         |
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|                     |            |   | y |                      |         |
|                     |            |   | . |                      |         |
|                     |            |   | ) |                      |         |
|                     |            |   | * |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| RESPONDENT *(Name,  |            |   |   |                      |         |
| title, department,  |            |   |   |                      |         |
| and institution)*   |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| TELEPHONE NUMBER    | SIGNATURE  |   |   |                      | DATE    |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+

PHS 416-1 (Rev. 9/08) Reference Page