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<tbody>
<tr class="odd">
<td colspan="43">Form Approved Through 12/31/07 OMB No. 0925-0002</td>
</tr>
<tr class="even">
<td colspan="23" rowspan="4"><p>Department of Health and Human
Services</p>
<p>Public Health Service</p>
<h1 id="niddk-nancy-nossal-fellowship-award"
class="Face-Page-Heading-1">NIDDK Nancy Nossal Fellowship Award </h1>
<h2 id="individual-fellowship-application">Individual Fellowship
Application</h2>
<p><em>Follow instructions carefully.</em></p>
<p><em>Do not exceed character length restrictions
indicated.</em></p></td>
<td colspan="20"><strong>LEAVE BLANK—For NIDDK use only.</strong></td>
</tr>
<tr class="odd">
<td colspan="4">Type</td>
<td colspan="5">Activity</td>
<td colspan="11">Number</td>
</tr>
<tr class="even">
<td colspan="9">Review Group</td>
<td colspan="11">Formerly</td>
</tr>
<tr class="odd">
<td colspan="9">Meeting Dates</td>
<td colspan="11">Date Received</td>
</tr>
<tr class="even">
<td colspan="43"><p><mark>1. TITLE OF RESEARCH TRAINING PROPOSAL</mark>
(Do not exceed 81 characters, including spaces and punctuation.)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="6">2. LEVEL OF FELLOWSHIP</td>
<td colspan="32"><p>3. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR
PROGRAM ANNOUNCEMENT</p>
<p><em>(If “Yes,” state number and title)</em></p></td>
<td colspan="5"> NO YES</td>
</tr>
<tr class="even">
<td colspan="6">     </td>
<td colspan="2">Number:</td>
<td colspan="7">     </td>
<td colspan="2">Title:</td>
<td colspan="26"></td>
</tr>
<tr class="odd">
<td colspan="14" rowspan="2"><p><mark>4a. NAME OF APPLICANT (Last,
First, Middle)</mark></p>
<p>     </p></td>
<td colspan="22" rowspan="2"><p>4b. ERA COMMONS USER NAME</p>
<p>     </p></td>
<td colspan="7"><mark>4c. HIGHEST DEGREE(S)</mark></td>
</tr>
<tr class="even">
<td colspan="3">    </td>
<td colspan="3">    </td>
<td>    </td>
</tr>
<tr class="odd">
<td colspan="22" rowspan="2"><p><mark>4d. PRESENT MAILING ADDRESS
<em>(Street, City, State, Zip Code)</em></mark></p>
<p>     </p></td>
<td colspan="21"><p>4e. PERMANENT MAILING ADDRESS <em>(Street, City,
State, Zip Code)</em></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="6"><mark>4f. E-MAIL ADDRESS:</mark></td>
<td colspan="15">     </td>
</tr>
<tr class="odd">
<td colspan="43"><mark>TELEPHONES AND FAX <em>(Area code, number and
extension)</em></mark></td>
</tr>
<tr class="even">
<td colspan="7"><p><mark>4g. OFFICE</mark></p>
<p>     </p></td>
<td colspan="12"><p>4h. HOME</p>
<p>     </p></td>
<td colspan="11"><p>4i. PERMANENT</p>
<p>     </p></td>
<td colspan="13"><p><mark>4j. FAX NUMBER</mark></p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="2">4k. </td>
<td colspan="14">U.S. CITIZEN OR U.S. NONCITIZEN NATIONAL</td>
<td colspan="2">or</td>
<td colspan="3"></td>
<td colspan="13">PERMANENT RESIDENT OF U.S.</td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="25">5. TRAINING UNDER PROPOSED AWARD (See Fields of
Training)</td>
<td colspan="18" rowspan="2"><p><mark>6. PRIOR AND/OR CURRENT NRSA
SUPPORT</mark><br />
<em>(Individual or Institutional)</em></p>
<p> NO YES <em>(If “Yes,” refer to item 24, Form Page 5)</em></p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>Discipline No.:</p>
<p>    </p></td>
<td colspan="22"><p>Subcategory Name:</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="9">7a. DATES OF PROPOSED AWARD</td>
<td colspan="17">7b. PROPOSED AWARD DURATION</td>
<td colspan="17">8. DEGREE SOUGHT DURING PROPOSED AWARD</td>
</tr>
<tr class="odd">
<td colspan="4"><p>From <em>(MM/DD/YY)</em>:</p>
<p>     </p></td>
<td colspan="5"><p>Through <em>(MM/DD/YY)</em>:</p>
<p>     </p></td>
<td colspan="17"><p><em>(in months)</em></p>
<p>  </p></td>
<td colspan="9"><p>Degree:</p>
<p>     </p></td>
<td colspan="8"><p>Expected Completion Date:</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2"><p>9. HUMAN SUBJECTS</p>
<p>RESEARCH</p>
<p> No Yes</p>
<p> Indefinite</p></td>
<td colspan="15"><p>9b. Human Subjects Assurance No.</p>
<p>     </p></td>
<td colspan="11">10. VERTEBRATE ANIMALS</td>
<td colspan="12"> No Yes</td>
</tr>
<tr class="odd">
<td colspan="5"><p>9c. Clinical Trial</p>
<p> No Yes</p></td>
<td colspan="10"><p>9d. NIH-defined Phase III</p>
<p>Clinical Trial No Yes</p></td>
<td colspan="9">10a. If “Yes,” IACUC approval Date</td>
<td colspan="14">10b. Animal Welfare Assurance No.</td>
</tr>
<tr class="even">
<td colspan="20"><p>9a. Research Exempt No Yes</p>
<p>If “Yes,” Exemption No.      </p></td>
<td colspan="9">     </td>
<td colspan="14">     </td>
</tr>
<tr class="odd">
<td colspan="20" rowspan="2"><p><mark>11. NAME OF SPONSOR (Last, First,
Middle Initial)</mark></p>
<p>     </p></td>
<td colspan="23">14. OFFICIAL SIGNING FOR SPONSORING INSTITUTION</td>
</tr>
<tr class="even">
<td colspan="4">Name</td>
<td colspan="19">     </td>
</tr>
<tr class="odd">
<td colspan="20"><mark>12. SPONSORING LABORATORY OR BRANCH</mark></td>
<td colspan="4">Title</td>
<td colspan="19">     </td>
</tr>
<tr class="even">
<td>Name</td>
<td colspan="19">     </td>
<td colspan="4" rowspan="2">Address</td>
<td colspan="19" rowspan="2">     </td>
</tr>
<tr class="odd">
<td>Address</td>
<td colspan="19">     </td>
</tr>
<tr class="even">
<td colspan="12">13a. ENTITY IDENTIFICATION NO.</td>
<td colspan="8">13b. DUNS NO.</td>
<td colspan="4">Tel:</td>
<td colspan="9">     </td>
<td colspan="4">Fax:</td>
<td colspan="6">     </td>
</tr>
<tr class="odd">
<td colspan="12">     </td>
<td colspan="8">     </td>
<td colspan="4">E-Mail:</td>
<td colspan="19">     </td>
</tr>
<tr class="even">
<td colspan="43"><mark>15. APPLICANT CERTIFICATION AND
ACCEPTANCE:</mark> I certify that the statements herein are true,
complete, and accurate to the best of my knowledge, and I agree to
comply with the terms and conditions of award if an award is issued as a
result of this application.</td>
</tr>
<tr class="odd">
<td colspan="11"><p><mark>SIGNATURE OF APPLICANT NAMED IN 4a.</mark></p>
<p><em>(In ink. “Per” signature not acceptable.)</em></p></td>
<td colspan="29"></td>
<td colspan="3"><p><mark>DATE</mark></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="43">16. SPONSOR AND SPONSORING INSTITUTION CERTIFICATION
AND ACCEPTANCE: We, the undersigned, certify that the statements herein
are true, complete, and accurate to the best of our knowledge. If this
application results in an award, appropriate training, adequate
facilities, and supervision will be provided, and we accept the
obligation to comply with the Public Health Service terms and conditions
of award.</td>
</tr>
<tr class="odd">
<td colspan="13"><p><mark>SIGNATURE OF SPONSOR NAMED IN 11.</mark></p>
<p>(In ink. “Per” signature not acceptable.)</p></td>
<td colspan="9"><p><mark>DATE</mark></p>
<p>     </p></td>
<td colspan="19"><p>SIGNATURE OF OFFICIAL NAMED IN 14.</p>
<p>(In ink. “Per” signature not acceptable.)</p></td>
<td colspan="2"><p>DATE</p>
<p>     </p></td>
</tr>
</tbody>
</table>

PHS 416-1 (Rev. 10/05) Face Page Form Page 1

+-----+-----------+--------------+-----+---+--------+---------------------+
| ##  |           |              |     |   | [NAME  |                     |
|  NI |           |              |     |   | OF     |                     |
| DDK |           |              |     |   | APP    |                     |
|  Na |           |              |     |   | LICANT |                     |
| ncy |           |              |     |   | *      |                     |
|  No |           |              |     |   | (Last, |                     |
| ssa |           |              |     |   | first, |                     |
| l F |           |              |     |   | middle |                     |
| ell |           |              |     |   | initi  |                     |
| ows |           |              |     |   | al)*]{ |                     |
| hip |           |              |     |   | .mark} |                     |
|  Aw |           |              |     |   |        |                     |
| ard |           |              |     |   |        |                     |
|   { |           |              |     |   |        |                     |
| #ni |           |              |     |   |        |                     |
| ddk |           |              |     |   |        |                     |
| -na |           |              |     |   |        |                     |
| ncy |           |              |     |   |        |                     |
| -no |           |              |     |   |        |                     |
| ssa |           |              |     |   |        |                     |
| l-f |           |              |     |   |        |                     |
| ell |           |              |     |   |        |                     |
| ows |           |              |     |   |        |                     |
| hip |           |              |     |   |        |                     |
| -aw |           |              |     |   |        |                     |
| ard |           |              |     |   |        |                     |
| -1} |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
| ##  |           |              |     |   |        |                     |
| Ind |           |              |     |   |        |                     |
| ivi |           |              |     |   |        |                     |
| dua |           |              |     |   |        |                     |
| l F |           |              |     |   |        |                     |
| ell |           |              |     |   |        |                     |
| ows |           |              |     |   |        |                     |
| hip |           |              |     |   |        |                     |
|  Ap |           |              |     |   |        |                     |
| pli |           |              |     |   |        |                     |
| cat |           |              |     |   |        |                     |
| ion |           |              |     |   |        |                     |
|  {# |           |              |     |   |        |                     |
| ind |           |              |     |   |        |                     |
| ivi |           |              |     |   |        |                     |
| dua |           |              |     |   |        |                     |
| l-f |           |              |     |   |        |                     |
| ell |           |              |     |   |        |                     |
| ows |           |              |     |   |        |                     |
| hip |           |              |     |   |        |                     |
| -ap |           |              |     |   |        |                     |
| pli |           |              |     |   |        |                     |
| cat |           |              |     |   |        |                     |
| ion |           |              |     |   |        |                     |
| -1} |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| **S |           |              |     |   |        |                     |
| PON |           |              |     |   |        |                     |
| SOR |           |              |     |   |        |                     |
| and |           |              |     |   |        |                     |
| C   |           |              |     |   |        |                     |
| o-S |           |              |     |   |        |                     |
| pon |           |              |     |   |        |                     |
| sor |           |              |     |   |        |                     |
| I   |           |              |     |   |        |                     |
| nfo |           |              |     |   |        |                     |
| rma |           |              |     |   |        |                     |
| tio |           |              |     |   |        |                     |
| n** |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [   |           |              | [   |   |        |                     |
| 17. |           |              | 18. |   |        |                     |
| SPO |           |              | C   |   |        |                     |
| NSO |           |              | o-S |   |        |                     |
| R]{ |           |              | PON |   |        |                     |
| .ma |           |              | SOR |   |        |                     |
| rk} |           |              | *(W |   |        |                     |
|     |           |              | hen |   |        |                     |
|     |           |              | ap  |   |        |                     |
|     |           |              | pli |   |        |                     |
|     |           |              | cab |   |        |                     |
|     |           |              | le* |   |        |                     |
|     |           |              | )]{ |   |        |                     |
|     |           |              | .ma |   |        |                     |
|     |           |              | rk} |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [1  |           |              | [N  |   |        |                     |
| 7a. |           |              | AME |   |        |                     |
| N   |           |              | AND |   |        |                     |
| AME |           |              | DE  |   |        |                     |
| AND |           |              | GRE |   |        |                     |
| DE  |           |              | E(S |   |        |                     |
| GRE |           |              | )]{ |   |        |                     |
| E(S |           |              | .ma |   |        |                     |
| )]{ |           |              | rk} |   |        |                     |
| .ma |           |              |     |   |        |                     |
| rk} |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| 1   |           |              | ERA |   |        |                     |
| 7b. |           |              | C   |   |        |                     |
| ERA |           |              | OMM |   |        |                     |
| C   |           |              | ONS |   |        |                     |
| OMM |           |              | U   |   |        |                     |
| ONS |           |              | SER |   |        |                     |
| U   |           |              | N   |   |        |                     |
| SER |           |              | AME |   |        |                     |
| N   |           |              |     |   |        |                     |
| AME |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [1  |           |              |     |   |        |                     |
| 7c. |           |              |     |   |        |                     |
| L   |           |              |     |   |        |                     |
| ABO |           |              |     |   |        |                     |
| RAT |           |              |     |   |        |                     |
| ORY |           |              |     |   |        |                     |
| OR  |           |              |     |   |        |                     |
| BR  |           |              |     |   |        |                     |
| ANC |           |              |     |   |        |                     |
| H]{ |           |              |     |   |        |                     |
| .ma |           |              |     |   |        |                     |
| rk} |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [1  |           |              |     |   |        |                     |
| 7d. |           |              |     |   |        |                     |
| S   |           |              |     |   |        |                     |
| ECT |           |              |     |   |        |                     |
| ION |           |              |     |   |        |                     |
| (if |           |              |     |   |        |                     |
| a   |           |              |     |   |        |                     |
| ppl |           |              |     |   |        |                     |
| ica |           |              |     |   |        |                     |
| ble |           |              |     |   |        |                     |
| )]{ |           |              |     |   |        |                     |
| .ma |           |              |     |   |        |                     |
| rk} |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [1  |           |              | [A  |   |        |                     |
| 7e. |           |              | ddr |   |        |                     |
| A   |           |              | ess |   |        |                     |
| ddr |           |              | :]{ |   |        |                     |
| ess |           |              | .ma |   |        |                     |
| :]{ |           |              | rk} |   |        |                     |
| .ma |           |              |     |   |        |                     |
| rk} |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [   |           |              | [   |   |        |                     |
| Tel |           |              | Tel |   |        |                     |
| eph |           |              | eph |   |        |                     |
| one |           |              | one |   |        |                     |
| :]{ |           |              | :]{ |   |        |                     |
| .ma |           |              | .ma |   |        |                     |
| rk} |           |              | rk} |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [   |           |              | [   |   |        |                     |
| Fax |           |              | Fax |   |        |                     |
| :]{ |           |              | :]{ |   |        |                     |
| .ma |           |              | .ma |   |        |                     |
| rk} |           |              | rk} |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [   |           |              | [   |   |        |                     |
| E-M |           |              | E-M |   |        |                     |
| ail |           |              | ail |   |        |                     |
| ]{. |           |              | :]{ |   |        |                     |
| mar |           |              | .ma |   |        |                     |
| k}: |           |              | rk} |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| *   |           |              |     |   |        |                     |
| *RE |           |              |     |   |        |                     |
| SEA |           |              |     |   |        |                     |
| RCH |           |              |     |   |        |                     |
| SUM |           |              |     |   |        |                     |
| MAR |           |              |     |   |        |                     |
| Y** |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
| [   |           |              |     |   |        |                     |
| 19. |           |              |     |   |        |                     |
| DE  |           |              |     |   |        |                     |
| SCR |           |              |     |   |        |                     |
| IPT |           |              |     |   |        |                     |
| ION |           |              |     |   |        |                     |
| :]{ |           |              |     |   |        |                     |
| .ma |           |              |     |   |        |                     |
| rk} |           |              |     |   |        |                     |
| See |           |              |     |   |        |                     |
| i   |           |              |     |   |        |                     |
| nst |           |              |     |   |        |                     |
| ruc |           |              |     |   |        |                     |
| tio |           |              |     |   |        |                     |
| ns. |           |              |     |   |        |                     |
| St  |           |              |     |   |        |                     |
| ate |           |              |     |   |        |                     |
| the |           |              |     |   |        |                     |
| a   |           |              |     |   |        |                     |
| ppl |           |              |     |   |        |                     |
| ica |           |              |     |   |        |                     |
| tio |           |              |     |   |        |                     |
| n's |           |              |     |   |        |                     |
| bro |           |              |     |   |        |                     |
| ad, |           |              |     |   |        |                     |
| lon |           |              |     |   |        |                     |
| g-t |           |              |     |   |        |                     |
| erm |           |              |     |   |        |                     |
| o   |           |              |     |   |        |                     |
| bje |           |              |     |   |        |                     |
| cti |           |              |     |   |        |                     |
| ves |           |              |     |   |        |                     |
| and |           |              |     |   |        |                     |
| sp  |           |              |     |   |        |                     |
| eci |           |              |     |   |        |                     |
| fic |           |              |     |   |        |                     |
| ai  |           |              |     |   |        |                     |
| ms, |           |              |     |   |        |                     |
| mak |           |              |     |   |        |                     |
| ing |           |              |     |   |        |                     |
| ref |           |              |     |   |        |                     |
| ere |           |              |     |   |        |                     |
| nce |           |              |     |   |        |                     |
| to  |           |              |     |   |        |                     |
| the |           |              |     |   |        |                     |
| hea |           |              |     |   |        |                     |
| lth |           |              |     |   |        |                     |
| re  |           |              |     |   |        |                     |
| lat |           |              |     |   |        |                     |
| edn |           |              |     |   |        |                     |
| ess |           |              |     |   |        |                     |
| of  |           |              |     |   |        |                     |
| the |           |              |     |   |        |                     |
| p   |           |              |     |   |        |                     |
| roj |           |              |     |   |        |                     |
| ect |           |              |     |   |        |                     |
| (i. |           |              |     |   |        |                     |
| e., |           |              |     |   |        |                     |
| rel |           |              |     |   |        |                     |
| eva |           |              |     |   |        |                     |
| nce |           |              |     |   |        |                     |
| to  |           |              |     |   |        |                     |
| the |           |              |     |   |        |                     |
| **m |           |              |     |   |        |                     |
| iss |           |              |     |   |        |                     |
| ion |           |              |     |   |        |                     |
| of  |           |              |     |   |        |                     |
| the |           |              |     |   |        |                     |
| a   |           |              |     |   |        |                     |
| gen |           |              |     |   |        |                     |
| cy* |           |              |     |   |        |                     |
| *). |           |              |     |   |        |                     |
| De  |           |              |     |   |        |                     |
| scr |           |              |     |   |        |                     |
| ibe |           |              |     |   |        |                     |
| con |           |              |     |   |        |                     |
| cis |           |              |     |   |        |                     |
| ely |           |              |     |   |        |                     |
| the |           |              |     |   |        |                     |
| re  |           |              |     |   |        |                     |
| sea |           |              |     |   |        |                     |
| rch |           |              |     |   |        |                     |
| des |           |              |     |   |        |                     |
| ign |           |              |     |   |        |                     |
| and |           |              |     |   |        |                     |
| m   |           |              |     |   |        |                     |
| eth |           |              |     |   |        |                     |
| ods |           |              |     |   |        |                     |
| for |           |              |     |   |        |                     |
| ach |           |              |     |   |        |                     |
| iev |           |              |     |   |        |                     |
| ing |           |              |     |   |        |                     |
| th  |           |              |     |   |        |                     |
| ese |           |              |     |   |        |                     |
| goa |           |              |     |   |        |                     |
| ls. |           |              |     |   |        |                     |
| De  |           |              |     |   |        |                     |
| scr |           |              |     |   |        |                     |
| ibe |           |              |     |   |        |                     |
| the |           |              |     |   |        |                     |
| rat |           |              |     |   |        |                     |
| ion |           |              |     |   |        |                     |
| ale |           |              |     |   |        |                     |
| and |           |              |     |   |        |                     |
| t   |           |              |     |   |        |                     |
| ech |           |              |     |   |        |                     |
| niq |           |              |     |   |        |                     |
| ues |           |              |     |   |        |                     |
| you |           |              |     |   |        |                     |
| w   |           |              |     |   |        |                     |
| ill |           |              |     |   |        |                     |
| use |           |              |     |   |        |                     |
| to  |           |              |     |   |        |                     |
| pur |           |              |     |   |        |                     |
| sue |           |              |     |   |        |                     |
| th  |           |              |     |   |        |                     |
| ese |           |              |     |   |        |                     |
| goa |           |              |     |   |        |                     |
| ls. |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
| [*  |           |              |     |   |        |                     |
| *DO |           |              |     |   |        |                     |
| NOT |           |              |     |   |        |                     |
| EXC |           |              |     |   |        |                     |
| EED |           |              |     |   |        |                     |
| THE |           |              |     |   |        |                     |
| SP  |           |              |     |   |        |                     |
| ACE |           |              |     |   |        |                     |
| PRO |           |              |     |   |        |                     |
| VID |           |              |     |   |        |                     |
| ED. |           |              |     |   |        |                     |
| **] |           |              |     |   |        |                     |
| {.u |           |              |     |   |        |                     |
| nde |           |              |     |   |        |                     |
| rli |           |              |     |   |        |                     |
| ne} |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+
|     |           |              |     |   |        |                     |
|     |           |              |     |   |        |                     |
+-----+-----------+--------------+-----+---+--------+---------------------+

PHS 416-1 (Rev. 10/05) Page 2 Number pages consecutively at the bottom
throughout Form Page 2\
the application. Do not use suffixes such as 2a, 2b.

+---+-----+------------+---+------+------+---+-------------+--------------+
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| - |     |            |   |      |      |   |             |              |
| 2 |     |            |   |      |      |   |             |              |
| } |     |            |   |      |      |   |             |              |
+---+-----+------------+---+------+------+---+-------------+--------------+
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+---+-----+------------+---+------+------+---+-------------+--------------+
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+---+-----+------------+---+------+------+---+-------------+--------------+
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+---+-----+------------+---+------+------+---+-------------+--------------+

PHS 416-1 (Rev. 10/05) Page 3 Form Page 3

+--------------------------------------+--------------+---+------+---+
| # NIDDK Nancy Nossal Fellow          | [NAME OF     |   |      |   |
| ship Award {#niddk-nancy-nossal-fell | APPLICANT    |   |      |   |
| owship-award-3 .Face-Page-Heading-1} | *(Last,      |   |      |   |
|                                      | first,       |   |      |   |
| ##                                   | middle       |   |      |   |
| Individual Fellowship Application {# | initi        |   |      |   |
| individual-fellowship-application-3} | al)*]{.mark} |   |      |   |
|                                      |              |   |      |   |
| ## [Table of Contents]{.mark}        |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| Section 1 --- Applicant              |              | * |      |   |
|                                      |              | * |      |   |
|                                      |              | P |      |   |
|                                      |              | a |      |   |
|                                      |              | g |      |   |
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|                                      |              | N |      |   |
|                                      |              | u |      |   |
|                                      |              | m |      |   |
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|                                      |              | r |      |   |
|                                      |              | s |      |   |
|                                      |              | * |      |   |
|                                      |              | * |      |   |
|                                      |              |   |      |   |
|                                      |              | * |      |   |
|                                      |              | ( |      |   |
|                                      |              | N |      |   |
|                                      |              | u |      |   |
|                                      |              | m |      |   |
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|                                      |              | p |      |   |
|                                      |              | a |      |   |
|                                      |              | g |      |   |
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|                                      |              | s |      |   |
|                                      |              | c |      |   |
|                                      |              | o |      |   |
|                                      |              | n |      |   |
|                                      |              | s |      |   |
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|                                      |              | i |      |   |
|                                      |              | v |      |   |
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|                                      |              | l |      |   |
|                                      |              | y |      |   |
|                                      |              | a |      |   |
|                                      |              | t |      |   |
|                                      |              | t |      |   |
|                                      |              | h |      |   |
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|                                      |              | b |      |   |
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|                                      |              | h |      |   |
|                                      |              | o |      |   |
|                                      |              | u |      |   |
|                                      |              | t |      |   |
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|                                      |              | h |      |   |
|                                      |              | e |      |   |
|                                      |              | a |      |   |
|                                      |              | p |      |   |
|                                      |              | p |      |   |
|                                      |              | l |      |   |
|                                      |              | i |      |   |
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|                                      |              | o |      |   |
|                                      |              | n |      |   |
|                                      |              | . |      |   |
|                                      |              | D |      |   |
|                                      |              | o |      |   |
|                                      |              | n |      |   |
|                                      |              | o |      |   |
|                                      |              | t |      |   |
|                                      |              | u |      |   |
|                                      |              | s |      |   |
|                                      |              | e |      |   |
|                                      |              | s |      |   |
|                                      |              | u |      |   |
|                                      |              | f |      |   |
|                                      |              | f |      |   |
|                                      |              | i |      |   |
|                                      |              | x |      |   |
|                                      |              | e |      |   |
|                                      |              | s |      |   |
|                                      |              | s |      |   |
|                                      |              | u |      |   |
|                                      |              | c |      |   |
|                                      |              | h |      |   |
|                                      |              | a |      |   |
|                                      |              | s |      |   |
|                                      |              | 6 |      |   |
|                                      |              | a |      |   |
|                                      |              | , |      |   |
|                                      |              | 6 |      |   |
|                                      |              | b |      |   |
|                                      |              | . |      |   |
|                                      |              | ) |      |   |
|                                      |              | * |      |   |
+--------------------------------------+--------------+---+------+---+
| Face Page                            |              |   | 1    |   |
+--------------------------------------+--------------+---+------+---+
| **Sponsor's** Contact **Information, |              |   | 2    |   |
| Description** (**Form Page 2**)      |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| Training & Career Goals, Activities  |              |   | 3    |   |
| Planned Under This Award, Training   |              |   |      |   |
| Site, Human Embryonic Stem Cells     |              |   |      |   |
| (Form Page 3)                        |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| Table of Contents (Form Page 4)      |              |   | 4    |   |
+--------------------------------------+--------------+---+------+---+
| Biographical **Sketch --             |              |   | [    | [ |
| Applicant/Fellow *(****Not to exceed |              |   |      | ] |
| 4 pages**)***                        |              |   | ]{.m | { |
|                                      |              |   | ark} | . |
|                                      |              |   |      | m |
|                                      |              |   |      | a |
|                                      |              |   |      | r |
|                                      |              |   |      | k |
|                                      |              |   |      | } |
+--------------------------------------+--------------+---+------+---+
| Previous **Research Experience**     |              |   | [    |   |
| (Form Page 5) *(Not to exceed 2      |              |   |      |   |
| pages*)                              |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| Research **Training Plan**           |              |   | [    |   |
|                                      |              |   |      |   |
|                                      |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
|                                      |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| A. Specific Aims                     |              |   | [    |   |
| ..................... *(Total of A-D |              |   |      |   |
| not to exceed 10 pages)*             |              |   | ]{.m |   |
| ........................             |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| B. Background/Significance           |              |   | [    |   |
| ......................               |              |   |      |   |
| .................................... |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| C. Preliminary Studies/Progress      |              |   | [    |   |
| Report                               |              |   |      |   |
| ...............................      |              |   | ]{.m |   |
| .................................... |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| D. Research Design and Methods       |              |   | [    |   |
|                                      |              |   |      |   |
|                                      |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
|                                      |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| E. Literature Cited                  |              |   | [    |   |
|                                      |              |   |      |   |
|                                      |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| F. Respective Contributions          |              |   | [    |   |
| ..........                           |              |   |      |   |
| .................................... |              |   | ]{.m |   |
| .................................... |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| G. Selection of Sponsor and          |              |   | [    |   |
| Institution                          |              |   |      |   |
| .................................    |              |   | ]{.m |   |
| .................................... |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
|                                      |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| Section 2 --- Sponsor's/Co-Sponsor's |              |   |      |   |
| Information                          |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| Facilities and Commitment -- Sponsor |              |   | [    |   |
| ..................................   |              |   |      |   |
| .................................... |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| Previous Trainees                    |              |   | [    |   |
|                                      |              |   |      |   |
|                                      |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| Training Plan, Environment, Research |              |   | [    |   |
| Facilities                           |              |   |      |   |
|                                      |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| Biographical Sketch---Sponsor (*Not  |              |   | [    |   |
| to exceed 4 pages*)                  |              |   |      |   |
|                                      |              |   | ]{.m |   |
|                                      |              |   | ark} |   |
+--------------------------------------+--------------+---+------+---+
| ***Previous Trainees, Training Plan, |              |   |      |   |
| Environment, Research Facilities,    |              |   |      |   |
| Current Number of Fellows/Trainees   |              |   |      |   |
| to be , and***                       |              |   |      |   |
|                                      |              |   |      |   |
| ***Current Number of                 |              |   |      |   |
| Fellows/Trainees to be Supervised    |              |   |      |   |
| sections not to exceed a total of 4  |              |   |      |   |
| pages.***                            |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| [Section 3 --- References *(Minimum  |              |   |      |   |
| of 3)*]{.mark}                       |              |   |      |   |
|                                      |              |   |      |   |
| *(See instructions for submission of |              |   |      |   |
| references.)*                        |              |   |      |   |
|                                      |              |   |      |   |
| List full name, institution, and     |              |   |      |   |
| department of individuals submitting |              |   |      |   |
| reference letters.                   |              |   |      |   |
|                                      |              |   |      |   |
|                                      |              |   |      |   |
+--------------------------------------+--------------+---+------+---+
| [Section 4 --- Appendix]{.mark}      |              |   |      |   |
|                                      |              |   |      |   |
| *(5 collated sets.* No *page         |              |   |      |   |
| numbering necessary. Not to exceed 3 |              |   |      |   |
| publications;)*                      |              |   |      |   |
|                                      |              |   |      |   |
| Check if Appendix is included        |              |   |      |   |
+--------------------------------------+--------------+---+------+---+

PHS 416-1 (Rev. 10/05) Page [4]{.underline} Form Page 4

+-----------------------------------+-----------------------------------+
| NIDDK Nancy Nossal Fellowship     | # [NAME OF APPLICANT *(Last,      |
| Award **Individual Fellowship     | first, middle initial)*]{.mark} { |
| Application**                     | #name-of-applicant-last-first-mid |
|                                   | dle-initial .Face-Page-Heading-1} |
| **Applicant/Fellow Biographical   |                                   |
| Sketch**                          | #                                 |
|                                   |   {#section .Face-Page-Heading-1} |
+-----------------------------------+-----------------------------------+

**\_*[DO NOT EXCEED 4 PAGES]{.underline}***

  -----------------------------------------------------------------------

  [NAME OF APPLICANT/FELLOW]{.mark} [POSITION TITLE]{.mark}

             

  eRA COMMONS USER NAME
  -----------------------------------------------------------------------

EDUCATION/TRAINING (Begin with baccalaureate or other initial
professional education, such as nursing, and include postdoctoral
training.)

+----------------+-----------------+----------------+-----------------+
| [INSTITUTION   | [DEGREE]{.mark} | [YEAR          | [FIELD OF       |
| AND            |                 | (s)]{.mark}    | STUDY]{.mark}   |
| LO             | *(if            |                |                 |
| CATION]{.mark} | applicable)*    |                | []{.mark}       |
|                |                 |                |                 |
|                |                 |                | []{.mark}       |
+----------------+-----------------+----------------+-----------------+
|                |                 |                |                 |
+----------------+-----------------+----------------+-----------------+

A.  **[Positions and Honors]{.mark}**

[]{.mark}

+----------------+------+------+---------+---------------+----------+
| [Activity/Occu | *[B  | [En  | [Field] | [I            | [Sup     |
| pation]{.mark} | egin | ding | {.mark} | nstitution/Co | ervisor/ |
|                | ning | Date |         | mpany]{.mark} | ]{.mark} |
|                | D    | ]{.m |         |               |          |
|                | ate] | ark} |         |               | [        |
|                | {.ma |      |         |               | Employer |
|                | rk}* | [(mm |         |               | ]{.mark} |
|                |      | /yy) |         |               |          |
|                | *    | ]{.m |         |               |          |
|                | [(mm | ark} |         |               |          |
|                | /yy] |      |         |               |          |
|                | {.ma |      |         |               |          |
|                | rk}* |      |         |               |          |
+----------------+------+------+---------+---------------+----------+
|                |      |      |         |               |          |
|                |      |      |         |               |          |
+----------------+------+------+---------+---------------+----------+

**[Academic and Professional Honors]{.mark}**

B.  **[Publications]{.mark}**

[]{.mark}

[]{.mark}

[]{.mark}

[]{.mark}

**PHS 416-1 (rev 10/05) Page\_\_\_**

+----+---+---+----------------------+------+----+----+----------------+
| #  |   |   |                      |      | [  |    |                |
| NI |   |   |                      |      | NA |    |                |
| DD |   |   |                      |      | ME |    |                |
| K  |   |   |                      |      | OF |    |                |
| Na |   |   |                      |      | A  |    |                |
| nc |   |   |                      |      | PP |    |                |
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| p  |   |   |                      |      | mi |    |                |
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|  { |   |   |                      |      | it |    |                |
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| -a |   |   |                      |      |    |    |                |
| wa |   |   |                      |      |    |    |                |
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| -4 |   |   |                      |      |    |    |                |
|  . |   |   |                      |      |    |    |                |
| Fa |   |   |                      |      |    |    |                |
| ce |   |   |                      |      |    |    |                |
| -P |   |   |                      |      |    |    |                |
| ag |   |   |                      |      |    |    |                |
| e- |   |   |                      |      |    |    |                |
| He |   |   |                      |      |    |    |                |
| ad |   |   |                      |      |    |    |                |
| in |   |   |                      |      |    |    |                |
| g- |   |   |                      |      |    |    |                |
| 1} |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
| #  |   |   |                      |      |    |    |                |
| #  |   |   |                      |      |    |    |                |
| In |   |   |                      |      |    |    |                |
| di |   |   |                      |      |    |    |                |
| vi |   |   |                      |      |    |    |                |
| du |   |   |                      |      |    |    |                |
| al |   |   |                      |      |    |    |                |
|  F |   |   |                      |      |    |    |                |
| el |   |   |                      |      |    |    |                |
| lo |   |   |                      |      |    |    |                |
| ws |   |   |                      |      |    |    |                |
| hi |   |   |                      |      |    |    |                |
| p  |   |   |                      |      |    |    |                |
| Ap |   |   |                      |      |    |    |                |
| pl |   |   |                      |      |    |    |                |
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| at |   |   |                      |      |    |    |                |
| io |   |   |                      |      |    |    |                |
| n  |   |   |                      |      |    |    |                |
| {# |   |   |                      |      |    |    |                |
| in |   |   |                      |      |    |    |                |
| di |   |   |                      |      |    |    |                |
| vi |   |   |                      |      |    |    |                |
| du |   |   |                      |      |    |    |                |
| al |   |   |                      |      |    |    |                |
| -f |   |   |                      |      |    |    |                |
| el |   |   |                      |      |    |    |                |
| lo |   |   |                      |      |    |    |                |
| ws |   |   |                      |      |    |    |                |
| hi |   |   |                      |      |    |    |                |
| p- |   |   |                      |      |    |    |                |
| ap |   |   |                      |      |    |    |                |
| pl |   |   |                      |      |    |    |                |
| ic |   |   |                      |      |    |    |                |
| at |   |   |                      |      |    |    |                |
| io |   |   |                      |      |    |    |                |
| n- |   |   |                      |      |    |    |                |
| 4} |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
| #  |   |   |                      |      |    |    |                |
| #  |   |   |                      |      |    |    |                |
| Pr |   |   |                      |      |    |    |                |
| ev |   |   |                      |      |    |    |                |
| io |   |   |                      |      |    |    |                |
| us |   |   |                      |      |    |    |                |
|  R |   |   |                      |      |    |    |                |
| es |   |   |                      |      |    |    |                |
| ea |   |   |                      |      |    |    |                |
| rc |   |   |                      |      |    |    |                |
| h  |   |   |                      |      |    |    |                |
| Ex |   |   |                      |      |    |    |                |
| pe |   |   |                      |      |    |    |                |
| ri |   |   |                      |      |    |    |                |
| en |   |   |                      |      |    |    |                |
| ce |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
| (  |   |   |                      |      |    |    |                |
| To |   |   |                      |      |    |    |                |
| be |   |   |                      |      |    |    |                |
| c  |   |   |                      |      |    |    |                |
| om |   |   |                      |      |    |    |                |
| pl |   |   |                      |      |    |    |                |
| et |   |   |                      |      |    |    |                |
| ed |   |   |                      |      |    |    |                |
| by |   |   |                      |      |    |    |                |
| a  |   |   |                      |      |    |    |                |
| pp |   |   |                      |      |    |    |                |
| li |   |   |                      |      |    |    |                |
| ca |   |   |                      |      |    |    |                |
| nt |   |   |                      |      |    |    |                |
| -- |   |   |                      |      |    |    |                |
| fo |   |   |                      |      |    |    |                |
| ll |   |   |                      |      |    |    |                |
| ow |   |   |                      |      |    |    |                |
| P  |   |   |                      |      |    |    |                |
| HS |   |   |                      |      |    |    |                |
| 4  |   |   |                      |      |    |    |                |
| 16 |   |   |                      |      |    |    |                |
| -1 |   |   |                      |      |    |    |                |
| in |   |   |                      |      |    |    |                |
| st |   |   |                      |      |    |    |                |
| ru |   |   |                      |      |    |    |                |
| ct |   |   |                      |      |    |    |                |
| io |   |   |                      |      |    |    |                |
| ns |   |   |                      |      |    |    |                |
| .) |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
| [2 |   |   |                      |      |    |    |                |
| 4. |   |   |                      |      |    |    |                |
| P  |   |   |                      |      |    |    |                |
| RI |   |   |                      |      |    |    |                |
| OR |   |   |                      |      |    |    |                |
| A  |   |   |                      |      |    |    |                |
| ND |   |   |                      |      |    |    |                |
| C  |   |   |                      |      |    |    |                |
| UR |   |   |                      |      |    |    |                |
| RE |   |   |                      |      |    |    |                |
| NT |   |   |                      |      |    |    |                |
| K  |   |   |                      |      |    |    |                |
| IR |   |   |                      |      |    |    |                |
| SC |   |   |                      |      |    |    |                |
| HS |   |   |                      |      |    |    |                |
| TE |   |   |                      |      |    |    |                |
| IN |   |   |                      |      |    |    |                |
| NR |   |   |                      |      |    |    |                |
| SA |   |   |                      |      |    |    |                |
| SU |   |   |                      |      |    |    |                |
| PP |   |   |                      |      |    |    |                |
| OR |   |   |                      |      |    |    |                |
| T. |   |   |                      |      |    |    |                |
| ]{ |   |   |                      |      |    |    |                |
| .m |   |   |                      |      |    |    |                |
| ar |   |   |                      |      |    |    |                |
| k} |   |   |                      |      |    |    |                |
| Li |   |   |                      |      |    |    |                |
| st |   |   |                      |      |    |    |                |
| ty |   |   |                      |      |    |    |                |
| pe |   |   |                      |      |    |    |                |
| (  |   |   |                      |      |    |    |                |
| in |   |   |                      |      |    |    |                |
| di |   |   |                      |      |    |    |                |
| vi |   |   |                      |      |    |    |                |
| du |   |   |                      |      |    |    |                |
| al |   |   |                      |      |    |    |                |
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| d/ |   |   |                      |      |    |    |                |
| or |   |   |                      |      |    |    |                |
| i  |   |   |                      |      |    |    |                |
| ns |   |   |                      |      |    |    |                |
| ti |   |   |                      |      |    |    |                |
| tu |   |   |                      |      |    |    |                |
| ti |   |   |                      |      |    |    |                |
| on |   |   |                      |      |    |    |                |
| al |   |   |                      |      |    |    |                |
| ), |   |   |                      |      |    |    |                |
| l  |   |   |                      |      |    |    |                |
| ev |   |   |                      |      |    |    |                |
| el |   |   |                      |      |    |    |                |
| (p |   |   |                      |      |    |    |                |
| re |   |   |                      |      |    |    |                |
| do |   |   |                      |      |    |    |                |
| ct |   |   |                      |      |    |    |                |
| or |   |   |                      |      |    |    |                |
| al |   |   |                      |      |    |    |                |
| or |   |   |                      |      |    |    |                |
| po |   |   |                      |      |    |    |                |
| st |   |   |                      |      |    |    |                |
| do |   |   |                      |      |    |    |                |
| ct |   |   |                      |      |    |    |                |
| or |   |   |                      |      |    |    |                |
| al |   |   |                      |      |    |    |                |
| ), |   |   |                      |      |    |    |                |
| da |   |   |                      |      |    |    |                |
| te |   |   |                      |      |    |    |                |
| s, |   |   |                      |      |    |    |                |
| a  |   |   |                      |      |    |    |                |
| nd |   |   |                      |      |    |    |                |
| g  |   |   |                      |      |    |    |                |
| ra |   |   |                      |      |    |    |                |
| nt |   |   |                      |      |    |    |                |
| or |   |   |                      |      |    |    |                |
| a  |   |   |                      |      |    |    |                |
| wa |   |   |                      |      |    |    |                |
| rd |   |   |                      |      |    |    |                |
| nu |   |   |                      |      |    |    |                |
| mb |   |   |                      |      |    |    |                |
| er |   |   |                      |      |    |    |                |
| s. |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
| 25 |   |   |                      |      |    |    |                |
| \. |   |   |                      |      |    |    |                |
| AP |   |   |                      |      |    |    |                |
| PL |   |   |                      |      |    |    |                |
| IC |   |   |                      |      |    |    |                |
| AT |   |   |                      |      |    |    |                |
| IO |   |   |                      |      |    |    |                |
| N( |   |   |                      |      |    |    |                |
| S) |   |   |                      |      |    |    |                |
| F  |   |   |                      |      |    |    |                |
| OR |   |   |                      |      |    |    |                |
| CO |   |   |                      |      |    |    |                |
| NC |   |   |                      |      |    |    |                |
| UR |   |   |                      |      |    |    |                |
| RE |   |   |                      |      |    |    |                |
| NT |   |   |                      |      |    |    |                |
| S  |   |   |                      |      |    |    |                |
| UP |   |   |                      |      |    |    |                |
| PO |   |   |                      |      |    |    |                |
| RT |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
|    |   |   | Using format below,  |      |    |    |                |
| NO | Y |   | list all support     |      |    |    |                |
|    | E |   | (training, research, |      |    |    |                |
|    | S |   | supplies, travel,    |      |    |    |                |
|    |   |   | etc.) applied for    |      |    |    |                |
|    |   |   | that would run       |      |    |    |                |
|    |   |   | concurrently with\   |      |    |    |                |
|    |   |   | the period covered   |      |    |    |                |
|    |   |   | by this application. |      |    |    |                |
|    |   |   | Include the type,    |      |    |    |                |
|    |   |   | dates, source, and   |      |    |    |                |
|    |   |   | amount.              |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
| T  |   |   |                      |      |    | Da |                |
| yp |   |   |                      |      |    | te |                |
| e: |   |   |                      |      |    | s* |                |
|    |   |   |                      |      |    | :* |                |
|    |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
| S  |   |   |                      |      |    | A  |                |
| ou |   |   |                      |      |    | mo |                |
| rc |   |   |                      |      |    | un |                |
| e* |   |   |                      |      |    | t* |                |
| :* |   |   |                      |      |    | :* |                |
+----+---+---+----------------------+------+----+----+----------------+
| T  |   |   |                      |      |    | Da |                |
| yp |   |   |                      |      |    | te |                |
| e* |   |   |                      |      |    | s* |                |
| :* |   |   |                      |      |    | :* |                |
|    |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
| S  |   |   |                      |      |    | A  |                |
| ou |   |   |                      |      |    | mo |                |
| rc |   |   |                      |      |    | un |                |
| e* |   |   |                      |      |    | t* |                |
| :* |   |   |                      |      |    | :* |                |
+----+---+---+----------------------+------+----+----+----------------+
| T  |   |   |                      |      |    | Da |                |
| yp |   |   |                      |      |    | te |                |
| e* |   |   |                      |      |    | s* |                |
| :* |   |   |                      |      |    | :* |                |
|    |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
| S  |   |   |                      |      |    | A  |                |
| ou |   |   |                      |      |    | mo |                |
| rc |   |   |                      |      |    | un |                |
| e* |   |   |                      |      |    | t* |                |
| :* |   |   |                      |      |    | :* |                |
+----+---+---+----------------------+------+----+----+----------------+
| [  |   |   |                      |      |    |    |                |
| 26 |   |   |                      |      |    |    |                |
| a. |   |   |                      |      |    |    |                |
| TI |   |   |                      |      |    |    |                |
| TL |   |   |                      |      |    |    |                |
| E( |   |   |                      |      |    |    |                |
| S) |   |   |                      |      |    |    |                |
| OF |   |   |                      |      |    |    |                |
| TH |   |   |                      |      |    |    |                |
| ES |   |   |                      |      |    |    |                |
| IS |   |   |                      |      |    |    |                |
| /D |   |   |                      |      |    |    |                |
| IS |   |   |                      |      |    |    |                |
| SE |   |   |                      |      |    |    |                |
| RT |   |   |                      |      |    |    |                |
| AT |   |   |                      |      |    |    |                |
| IO |   |   |                      |      |    |    |                |
| N( |   |   |                      |      |    |    |                |
| S) |   |   |                      |      |    |    |                |
| ]{ |   |   |                      |      |    |    |                |
| .m |   |   |                      |      |    |    |                |
| ar |   |   |                      |      |    |    |                |
| k} |   |   |                      |      |    |    |                |
| (P |   |   |                      |      |    |    |                |
| re |   |   |                      |      |    |    |                |
| do |   |   |                      |      |    |    |                |
| ct |   |   |                      |      |    |    |                |
| or |   |   |                      |      |    |    |                |
| al |   |   |                      |      |    |    |                |
| a  |   |   |                      |      |    |    |                |
| nd |   |   |                      |      |    |    |                |
| Se |   |   |                      |      |    |    |                |
| ni |   |   |                      |      |    |    |                |
| or |   |   |                      |      |    |    |                |
| F  |   |   |                      |      |    |    |                |
| el |   |   |                      |      |    |    |                |
| lo |   |   |                      |      |    |    |                |
| ws |   |   |                      |      |    |    |                |
| hi |   |   |                      |      |    |    |                |
| ps |   |   |                      |      |    |    |                |
| om |   |   |                      |      |    |    |                |
| it |   |   |                      |      |    |    |                |
| th |   |   |                      |      |    |    |                |
| is |   |   |                      |      |    |    |                |
| s  |   |   |                      |      |    |    |                |
| ec |   |   |                      |      |    |    |                |
| ti |   |   |                      |      |    |    |                |
| on |   |   |                      |      |    |    |                |
| .) |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
| [  |   |   |                      | [TI  |    |    |                |
| 26 |   |   |                      | TLE, |    |    |                |
| b. |   |   |                      | DEP  |    |    |                |
| NA |   |   |                      | ARTM |    |    |                |
| ME |   |   |                      | ENT, |    |    |                |
| OF |   |   |                      | AND  |    |    |                |
| DI |   |   |                      | INS  |    |    |                |
| SS |   |   |                      | TITU |    |    |                |
| ER |   |   |                      | TION |    |    |                |
| TA |   |   |                      | ]{.m |    |    |                |
| TI |   |   |                      | ark} |    |    |                |
| ON |   |   |                      |      |    |    |                |
| A  |   |   |                      |      |    |    |                |
| DV |   |   |                      |      |    |    |                |
| IS |   |   |                      |      |    |    |                |
| OR |   |   |                      |      |    |    |                |
| OR |   |   |                      |      |    |    |                |
| C  |   |   |                      |      |    |    |                |
| HI |   |   |                      |      |    |    |                |
| EF |   |   |                      |      |    |    |                |
| OF |   |   |                      |      |    |    |                |
| SE |   |   |                      |      |    |    |                |
| RV |   |   |                      |      |    |    |                |
| IC |   |   |                      |      |    |    |                |
| E\ |   |   |                      |      |    |    |                |
| ]{ |   |   |                      |      |    |    |                |
| .m |   |   |                      |      |    |    |                |
| ar |   |   |                      |      |    |    |                |
| k} |   |   |                      |      |    |    |                |
| (* |   |   |                      |      |    |    |                |
| If |   |   |                      |      |    |    |                |
| r  |   |   |                      |      |    |    |                |
| ef |   |   |                      |      |    |    |                |
| er |   |   |                      |      |    |    |                |
| en |   |   |                      |      |    |    |                |
| ce |   |   |                      |      |    |    |                |
| re |   |   |                      |      |    |    |                |
| po |   |   |                      |      |    |    |                |
| rt |   |   |                      |      |    |    |                |
| n  |   |   |                      |      |    |    |                |
| ot |   |   |                      |      |    |    |                |
| i  |   |   |                      |      |    |    |                |
| nc |   |   |                      |      |    |    |                |
| lu |   |   |                      |      |    |    |                |
| de |   |   |                      |      |    |    |                |
| d, |   |   |                      |      |    |    |                |
| e  |   |   |                      |      |    |    |                |
| xp |   |   |                      |      |    |    |                |
| la |   |   |                      |      |    |    |                |
| in |   |   |                      |      |    |    |                |
| w  |   |   |                      |      |    |    |                |
| hy |   |   |                      |      |    |    |                |
| n  |   |   |                      |      |    |    |                |
| o[ |   |   |                      |      |    |    |                |
| t. |   |   |                      |      |    |    |                |
| )] |   |   |                      |      |    |    |                |
| {. |   |   |                      |      |    |    |                |
| ma |   |   |                      |      |    |    |                |
| rk |   |   |                      |      |    |    |                |
| }* |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
| [2 |   |   |                      |      |    |    |                |
| 7. |   |   |                      |      |    |    |                |
| DO |   |   |                      |      |    |    |                |
| CT |   |   |                      |      |    |    |                |
| OR |   |   |                      |      |    |    |                |
| AL |   |   |                      |      |    |    |                |
| DI |   |   |                      |      |    |    |                |
| SS |   |   |                      |      |    |    |                |
| ER |   |   |                      |      |    |    |                |
| TA |   |   |                      |      |    |    |                |
| TI |   |   |                      |      |    |    |                |
| ON |   |   |                      |      |    |    |                |
| A  |   |   |                      |      |    |    |                |
| ND |   |   |                      |      |    |    |                |
| O  |   |   |                      |      |    |    |                |
| TH |   |   |                      |      |    |    |                |
| ER |   |   |                      |      |    |    |                |
| RE |   |   |                      |      |    |    |                |
| SE |   |   |                      |      |    |    |                |
| AR |   |   |                      |      |    |    |                |
| CH |   |   |                      |      |    |    |                |
| EX |   |   |                      |      |    |    |                |
| PE |   |   |                      |      |    |    |                |
| RI |   |   |                      |      |    |    |                |
| EN |   |   |                      |      |    |    |                |
| CE |   |   |                      |      |    |    |                |
| ]{ |   |   |                      |      |    |    |                |
| .m |   |   |                      |      |    |    |                |
| ar |   |   |                      |      |    |    |                |
| k} |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
| (N |   |   |                      |      |    |    |                |
| ot |   |   |                      |      |    |    |                |
| to |   |   |                      |      |    |    |                |
| ex |   |   |                      |      |    |    |                |
| ce |   |   |                      |      |    |    |                |
| ed |   |   |                      |      |    |    |                |
| 2  |   |   |                      |      |    |    |                |
| p  |   |   |                      |      |    |    |                |
| ag |   |   |                      |      |    |    |                |
| es |   |   |                      |      |    |    |                |
| .) |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
|    |   |   |                      |      |    |    |                |
+----+---+---+----------------------+------+----+----+----------------+

PHS 416-1 (Rev. 10/05) Page [   ]{.underline} Form Page 5

+------------------------------------------+---------------------------+
| # NIDDK Nancy Nossal                     | [NAME OF APPLICANT (Last, |
|  Fellowship Award  {#niddk-nancy-nossal- | first, middle             |
| fellowship-award-5 .Face-Page-Heading-1} | initial)]{.mark}          |
|                                          |                           |
| ## Individual Fellowship Applicatio      |                           |
| n {#individual-fellowship-application-5} |                           |
|                                          |                           |
| **Continuation Page**                    |                           |
+------------------------------------------+---------------------------+

**Research Training Plan**

**Insert the information for sections A-D on additional pages.**

[A. Specific Aims *(Total of A-D not to exceed 10 pages) *]{.mark}

B.  [Background/Significance]{.mark}

C.  [Preliminary Studies/Progress Report]{.mark}

D.  [Research Design and Methods]{.mark}

[]{.mark}

E.  [Literature Cited]{.mark}

[]{.mark}

     

F.  [Respective Contributions]{.mark}

[]{.mark}

     

G.  [Selection of Sponsor and Institution]{.mark}

[]{.mark}

     

PHS 416-1 (Rev. 10/05) Page [   ]{.underline}

+-----------------------------------------+----------------------------+
| # NIDDK Nancy Nossal F                  | [NAME OF APPLICANT (Last,  |
| ellowship Award  {#niddk-nancy-nossal-f | first, middle              |
| ellowship-award-6 .Face-Page-Heading-1} | initial)]{.mark}           |
|                                         |                            |
| ## Individual Fellowship Application    |                            |
|  {#individual-fellowship-application-6} |                            |
|                                         |                            |
| **Facilities and Commitment**           |                            |
|                                         |                            |
| (To be completed by sponsor)            |                            |
+-----------------------------------------+----------------------------+
|                                         |                            |
+-----------------------------------------+----------------------------+
| **[Sponsor's Previous                   |                            |
| Fellow/Trainees]{.mark}**               |                            |
+-----------------------------------------+----------------------------+
| *Give total number of pre- and          |                            |
| postdoctoral individuals and provide    |                            |
| information on a representative five.   |                            |
| List their present employing            |                            |
| organizations and position titles or    |                            |
| occupations.*                           |                            |
+-----------------------------------------+----------------------------+
|                                         |                            |
+-----------------------------------------+----------------------------+
| **[Facilities and Commitment            |                            |
| Statement]{.mark}**                     |                            |
+-----------------------------------------+----------------------------+
| *In the space below and on continuation |                            |
| pages, complete the following items.*   |                            |
+-----------------------------------------+----------------------------+
| [**Training Plan, Environment, Research |                            |
| Facilities**.]{.mark}                   |                            |
|                                         |                            |
| -   Describe the research training plan |                            |
|     for the applicant, include such     |                            |
|     items as classes, seminars, and     |                            |
|     opportunities for interaction with  |                            |
|     groups and scientists. Describe the |                            |
|     research environment and available  |                            |
|     research facilities and equipment.  |                            |
|     Include information that will help  |                            |
|                                         |                            |
| > reviewing groups evaluate the         |                            |
| > applicant and proposed training.      |                            |
| > Indicate the relationship of the      |                            |
| > proposed research training to the     |                            |
| > applicant's career. Describe the      |                            |
| > skill, techniques, etc., that the     |                            |
| > applicant will learn and relate these |                            |
| > to the applicant's career goals.      |                            |
|                                         |                            |
|                                         |                            |
|                                         |                            |
| -   Number of Fellows/Trainees that     |                            |
|     will be supervised (in additional   |                            |
|     to the applicant) by the sponsor.   |                            |
|     Indicate Pre or Postdoctoral.       |                            |
|                                         |                            |
|                                         |                            |
|                                         |                            |
| -   Applicant's qualifications and      |                            |
|     potential for a research career.    |                            |
|                                         |                            |
|                                         |                            |
+-----------------------------------------+----------------------------+

+-----------------------------------------------------------------------+
| Certification:                                                        |
|                                                                       |
| The undersigned certify that the statements herein are true, complete |
| and accurate to the best of our knowledge. If this application        |
| results in an award, appropriate training, adequate facilities, and   |
| supervision will be provided, and we accept the obligation to comply  |
| with the Public Health Service terms and conditions of the award. We  |
| are aware that any false, fictitious, fraudulent statement or claim   |
| may subject us to criminal, civil, or administrative penalties.       |
+-----------------------------------------------------------------------+

+-------------------+----------------------+-------------+-----------+
| **[Si             | **[Typed             | **[Offic    | **[Date]  |
| gnature]{.mark}** | Name]{.mark}**       | e]{.mark}** | {.mark}** |
|                   |                      |             |           |
|                   |                      | **[Telephon |           |
|                   |                      | e]{.mark}** |           |
+-------------------+----------------------+-------------+-----------+
| **[               |                      |             |           |
| Sponsor]{.mark}** |                      |             |           |
+-------------------+----------------------+-------------+-----------+
| **Lab or Branch** |                      |             |           |
|                   |                      |             |           |
| **Chief**         |                      |             |           |
|                   |                      |             |           |
| **[(signature not |                      |             |           |
| required of       |                      |             |           |
| Chief)]{.mark}**  |                      |             |           |
+-------------------+----------------------+-------------+-----------+

PHS 416-1 (Rev. 10/05) Page [   ]{.underline}

+-----------------------------------+----------------------------------+
| #                                 | [NAME OF APPLICANT (Last, first, |
|  NIDDK Nancy Nossal Fellowship Aw | middle initial)]{.mark}          |
| ard  {#niddk-nancy-nossal-fellows |                                  |
| hip-award-7 .Face-Page-Heading-1} |                                  |
|                                   |                                  |
| ##                                |                                  |
|                                   |                                  |
| ## Indivi                         |                                  |
| dual Fellowship Application {#ind |                                  |
| ividual-fellowship-application-7} |                                  |
|                                   |                                  |
| **Sponsor/CO-Sponsor Biographical |                                  |
| Sketch**                          |                                  |
|                                   |                                  |
| (To be completed by sponsor)      |                                  |
+-----------------------------------+----------------------------------+

+---------------------------------+---+-------+--------+-----------------+
| **SPONSOR/CO-SPONSOR            |   |       |        |                 |
| BIOGRAPHICAL SKETCH**           |   |       |        |                 |
|                                 |   |       |        |                 |
| Provide the following           |   |       |        |                 |
| information for the sponsor     |   |       |        |                 |
| (co-sponsor). **DO NOT EXCEED   |   |       |        |                 |
| FOUR PAGES.**                   |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
|                                 |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
| [NAME OF SPONSOR                |   | [POS  |        |                 |
| (CO-SPONSOR)]{.mark}            |   | ITION |        |                 |
|                                 |   | TIT   |        |                 |
|                                 |   | LE]{. |        |                 |
|                                 |   | mark} |        |                 |
+---------------------------------+---+-------+--------+-----------------+
| eRA COMMONS USER NAME           |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
| [EDUCATION/TRAINING]{.mark}     |   |       |        |                 |
| *(Begin with baccalaureate or   |   |       |        |                 |
| other initial professional      |   |       |        |                 |
| education, such as nursing, and |   |       |        |                 |
| include postdoctoral            |   |       |        |                 |
| training.)*                     |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
| [INSTITUTION AND                | [ |       | [YEA   | [FIELD OF       |
| LOCATION]{.mark}                | D |       | R(s)]{ | STUDY]{.mark}   |
|                                 | E |       | .mark} |                 |
|                                 | G |       |        |                 |
|                                 | R |       |        |                 |
|                                 | E |       |        |                 |
|                                 | E |       |        |                 |
|                                 | ] |       |        |                 |
|                                 | { |       |        |                 |
|                                 | . |       |        |                 |
|                                 | m |       |        |                 |
|                                 | a |       |        |                 |
|                                 | r |       |        |                 |
|                                 | k |       |        |                 |
|                                 | } |       |        |                 |
|                                 |   |       |        |                 |
|                                 | * |       |        |                 |
|                                 | ( |       |        |                 |
|                                 | i |       |        |                 |
|                                 | f |       |        |                 |
|                                 | a |       |        |                 |
|                                 | p |       |        |                 |
|                                 | p |       |        |                 |
|                                 | l |       |        |                 |
|                                 | i |       |        |                 |
|                                 | c |       |        |                 |
|                                 | a |       |        |                 |
|                                 | b |       |        |                 |
|                                 | l |       |        |                 |
|                                 | e |       |        |                 |
|                                 | ) |       |        |                 |
|                                 | * |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
|                                 |   |       |        |                 |
+---------------------------------+---+-------+--------+-----------------+

-   **[Positions and Honors.]{.mark}** List in chronological order
    previous positions, concluding with your present position. List any
    honors. Include present membership on any Federal Government
    advisory committee.

-   **[Selected peer-reviewed publications]{.mark}** (in chronological
    order). Do not include publications submitted or in preparation.

PHS 416-1 (Rev. 10/05) Page [   ]{.underline}

+-----+--------------------------------------------------+-------------+
|     | # NI                                             |             |
|     | DDK Nancy Nossal Fellowship Award  {#niddk-nancy |             |
|     | -nossal-fellowship-award-8 .Face-Page-Heading-1} |             |
|     |                                                  |             |
|     | > Individual Fellowship Application              |             |
+-----+--------------------------------------------------+-------------+
|     | > Applicant's Instructions for                   |             |
|     | >                                                |             |
|     | > Submission of References                       |             |
+-----+--------------------------------------------------+-------------+
|     | > This notice explains the submission of         |             |
|     | > references for the Dr. Nancy Nossal Fellowship |             |
|     | > Award Individual Fellowship Application.       |             |
|     | > Applications will not be reviewed unless at    |             |
|     | > least three (3) references are received by the |             |
|     | > application deadline. Applicants are           |             |
|     | > responsible for complete applications reaching |             |
|     | > the NIDDK Fellowship Office 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.                                    |             |
+-----+--------------------------------------------------+-------------+
|     |                                                  |             |
+-----+--------------------------------------------------+-------------+

> PHS 416-1 (Rev. 10/05) Page [   ]{.underline}

+--------+---------------------------------------------------+---------+
|        | #                                                 |         |
|        | NIDDK Nancy Nossal Fellowship Award  {#niddk-nanc |         |
|        | y-nossal-fellowship-award-9 .Face-Page-Heading-1} |         |
|        |                                                   |         |
|        | > Individual Fellowship Application               |         |
+--------+---------------------------------------------------+---------+
|        | > **Note to Respondent**                          |         |
+--------+---------------------------------------------------+---------+
|        | > The applicant is applying for a competitive,    |         |
|        | > National Institutes of Health (NIH), National   |         |
|        | > Institute of Diabetes and Digestive and Kidney  |         |
|        | > Disease (NIDDK) **Nancy Nossal Fellowship       |         |
|        | > Award** 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 the NIDDK        |         |
|        | > committee of consultants in assessing the       |         |
|        | > 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 NIDDK Fellowship Office        |         |
|        | > (address below) 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.                                         |         |
+--------+---------------------------------------------------+---------+
|        |                                                   |         |
+--------+---------------------------------------------------+---------+
|        | > The letters of reference may be sent to the     |         |
|        | > NIDDK Fellowship Office by one of the following |         |
|        | > methods:                                        |         |
|        | >                                                 |         |
|        | > **Fax**- On letterhead from the Institution     |         |
|        | > that the recommending person represents to      |         |
|        | >                                                 |         |
|        | > **301 402-7461**                                |         |
|        | >                                                 |         |
|        | > [Or]{.underline}                                |         |
|        | >                                                 |         |
|        | > **E-mai**l- From the institution e-mail account |         |
|        | > that the recommending person represents to      |         |
|        | >                                                 |         |
|        | > **<Fellowships@intra.niddk.nih.gov> or          |         |
|        | > <LorraineM@intra.niddk.nih.gov>**               |         |
|        | >                                                 |         |
|        | > [Or]{.underline}                                |         |
|        | >                                                 |         |
|        | > **Mail** - Ms. Lorraine Moore                   |         |
|        | >                                                 |         |
|        | > NIDDK Fellowship Office                         |         |
|        | >                                                 |         |
|        | > Division of Intramural Research                 |         |
|        | >                                                 |         |
|        | > Building 12A, Room 3011                         |         |
|        | >                                                 |         |
|        | > 12 South Drive (MSC 5632)                       |         |
|        | >                                                 |         |
|        | > Bethesda, Maryland 20892-5632                   |         |
+--------+---------------------------------------------------+---------+

+---------------------+------------+---+---+----------------------+---------+
| Form Approved       |            |   |   |                      |         |
| Through 10/31/08    |            |   |   |                      |         |
| OMB No. 0925-0002   |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| ## Reference        |            |   |   | **(Applicant         |         |
|                     |            |   |   | completes this       |         |
| # NIDD              |            |   |   | block.)**            |         |
| K Nancy Nossal Fell |            |   |   |                      |         |
| owship Award  {#nid |            |   |   |                      |         |
| dk-nancy-nossal-fel |            |   |   |                      |         |
| lowship-award-10 .F |            |   |   |                      |         |
| ace-Page-Heading-1} |            |   |   |                      |         |
|                     |            |   |   |                      |         |
| ## Individual Fell  |            |   |   |                      |         |
| owship Application  |            |   |   |                      |         |
| {#individual-fellow |            |   |   |                      |         |
| ship-application-8} |            |   |   |                      |         |
|                     |            |   |   |                      |         |
| #                   |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
|                     |            |   |   | 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 |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | v |                      |         |
|                     |            |   | i |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | , |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | t |                      |         |
|                     |            |   | h |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | ) |                      |         |
|                     |            |   | ( |                      |         |
|                     |            |   | U |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | c |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | n |                      |         |
|                     |            |   | t |                      |         |
|                     |            |   | i |                      |         |
|                     |            |   | n |                      |         |
|                     |            |   | u |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | t |                      |         |
|                     |            |   | i |                      |         |
|                     |            |   | o |                      |         |
|                     |            |   | n |                      |         |
|                     |            |   | p |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | g |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | n |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | c |                      |         |
|                     |            |   | e |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | s |                      |         |
|                     |            |   | a |                      |         |
|                     |            |   | r |                      |         |
|                     |            |   | y |                      |         |
|                     |            |   | . |                      |         |
|                     |            |   | ) |                      |         |
|                     |            |   | * |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| RESPONDENT *(Name,  |            |   |   |                      |         |
| title, department,  |            |   |   |                      |         |
| and institution)*   |            |   |   |                      |         |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+
| TELEPHONE NUMBER    | SIGNATURE  |   |   |                      | DATE    |
|                     |            |   |   |                      |         |
|                     |            |   |   |                      |         |
+---------------------+------------+---+---+----------------------+---------+

PHS 416-1 (Rev. 10/05) Reference Page