Your first name:
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Your middle name:(Enter "N/A" if none)
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Your last name:
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Primary Street Address:
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Primary City:
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Primary Zip:
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Primary State:
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If you do not already have one, you will be given one when you are appointed. It is required when a trainee is supported by federal grants.
ORCID:* If you do not have one already and would like to create one, please visit https://orcid.org/
It will be required after being accepted to the training program.
Please provide a current email address:
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Please provide a secondary email address:
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Please provide an e-mail address that is not affiliated with any institution.
Phone number:
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Date of birth:
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Today M-D-Y
Gender:
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Male Female Other Prefer not to answer
Race:
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American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White More Than One Race Unknown Prefer not to answer
Ethnicity:
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Hispanic or Latino Non-Hispanic Unknown Prefer not to answer
Disadvantaged? Criteria: 1) comes from low-income background and/or 2) comes from social/ cultural/ educational environment (i.e.: certain inner-city/rural that demonstrably and recently directly inhibited individuals from obtaining knowledge, skills and abilities necessary to develop and participate in research careers) https://era.nih.gov/commons/disadvantaged_def.htm
* must provide value
Yes No Prefer not to answer
Disability?
(Those with physical or mental impairments that substantially limits one or more major life activities)
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Yes No Prefer not to answer
Citizenship:Eligible applicants must be citizens or non-citizen nationals of the United States, or must be lawfully admitted to the United States for permanent residence and have in their possession a currently valid Permanent Resident Card (USCIS Form I-551) or other legal verification of such status. Non-citizen nationals are persons born in lands that are not States but are under U.S. sovereignty, jurisdiction, or administration (e.g., American Samoa). Individuals on temporary or student visas are not eligible.
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U.S. citizen Non U.S. citizen with permanent residency Non U.S. citizen, will have permanent residency prior to the program start date
Which T32 Track are you applying for? (Predoctoral or Postdoctoral)
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Predoctoral
Postdoctoral
Department of your primary appointment:
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Anesthesiology Biochemistry Biomedical Informatics Biostatistics Cancer Biology Cardiac Surgery Cell and Developmental Biology Emergency Medicine Family Medicine Hearing and Speech Sciences Medicine Molecular Physiology and Biophysics Neurology Neurological Surgery Obstetrics and Gynecology Ophthalmology and Visual Sciences Oral Maxillofacial Surgery Orthopaedic Surgery and Rehabilitation Otolaryngology Pathology Microbiology and Immunology Pediatric Surgery Pediatrics Pharmacology Plastic Surgery Preventive Medicine Psychiatry Radiation Oncology Radiology and Radiological Sciences Surgery Thoracic Surgery Urologic Surgery Other
Please specify your department:
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Division: (Please indicate N/A if not applicable)
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Current protected research time (%)
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Prior Full-Time Research Experience* Prior Full-Time Research Experience: Report the number of months of full-time research following college. Do not include labs associated with a course
Receive Funding from Your Current Program?* Per NIH policy, no individual trainee may receive more than three years of aggregate Kirchstein-NRSA support at the post-doctoral level
Yes
No
Receiving Funding ExplanationExample: T32, R01, non-federal foundation, etc. If applicable, please provide the grant #.
Academic Rank? (Fellow, Postdoc, Predoc, Other)
Fellow Postdoc Predoc Other
Tenure/Investigator Track Clinical Track Research Track Not Applicable/Not Assigned
Do you have a primary doctoral degree already?
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Yes
No
Please select your primary doctoral degree.
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MD PhD MD/PhD Other/International degree
Please specify (e.g., PharmD, PsyD):
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Month and year degree received: (MM/YYYY)
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The institution which granted this degree:
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Institution location (city, state-province, country)
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Fellowship?
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Yes
No
When did you complete your fellowship?
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Today M-D-Y
Do you have another doctoral degree?
Yes
No
Please select your second doctoral degree.
MD PhD MD/PhD Other/International degree
Please specify (e.g., PharmD, PsyD):
Month and year degree received: (MM/YYYY)
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Please name the institution which granted this degree.
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Institution location (city, state-province, country)
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Do you have additional graduate degree(s)?
Yes
No
Please select your graduate degree.
MPH MSCI MS Other
Month and year degree received: (MM/YYYY)
Please name the institution which granted this degree.
Institution location (city, state-province, country)
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Do you have another graduate degree?
Yes
No
Please select your graduate degree.
MPH MSCI MS Other
Month and year degree received: (MM/YYYY)
Please name the institution which granted this degree.
Institution location (city, state-province, country)
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Do you have another graduate degree?
Yes
No
Please select your graduate degree.
MPH MSCI MS Other
Month and year degree received:
Please name the institution which granted this degree.
Institution location (city, state-province, country)
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Are you currently in a degree program?
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Yes
No
Please select your degree program.
MS MSCI MPH PhD MD/PhD Other
Please specify your degree program:
Please name the institution which will grant this degree.
Institution location (city, state-province, country)
When is your anticipated graduation? (MM/YYYY)
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What is your research project title?
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Please choose one of the following options. Note the special obligation imposed on candidates with concurrent grant.
I am NOT currently applying for other individual NIH career development awards or other federal funding.
I have a pending application for an individual NIH Career Development Award (e.g. K01, K07, K08, K23) or an equivalent award. I understand that if I am chosen for this training program and the other application is funded, I will relinquish the training grant funding when the other award starts. I also understand that I am encouraged to complete both the formal training and the formal curricular activities of the training program to the extent these do not interfere with my other career development plans.
What K or other Career Development award type?
K01
K02
K07
K08
K22
K23
K25
K99/R00
WU CDA
Foundation
Other
What other type of award? Please give name of foundation or organization
What is the anticipated funding date of the proposal listed above?
PRIMARY mentor (Please select your mentor from the list)
* must provide value
Ances, Beau M. Balls-Berry, Joyce E. Bateman, Randall J. Benzinger, Tammie L. Brett, Thomas J. Campbell, Meghan C. Cirrito, John R. Colonna, Marco. Cruchaga, Carlos Davis, Albert A. (Gus) Diantonio, Aaron Gordon, Brian Harari, Oscar Hassenstab, Jason J. Head, Denise P. Hershey, Tamara G. Holtzman, David M. Hudson, Darrell L. Jackrel, Meredith Karch, Celeste M. Kipnis, Jonathan Lucey, Brendan P. McDade, Eric M. Miller, Timothy M. Morris, John Morrow-Howell, Nancy L. Musiek, Erik S. Pappu, Rohit V. Perrin, Richard J. Piccio, Laura Schindler, Suzanne E. Snider, Barbara J. Sotiras, Aristeidis Stark, Susan L. Weihl, Conrad Xiong, Chengjie Yoo, Andrew Zacks, Jeffrey M. Not included on the list
Please enter your PRIMARY mentor name (Last Name, First Name) * If you are proposing a mentor who is not listed, he or she would need to be approved by NIH prior to the trainee being appointed to the training program which might create a delay or the request might be rejected by NIH.
* must provide value
Do you have a secondary mentor?
* must provide value
Yes
No
SECONDARY mentor (Please select your mentor from the list)
* must provide value
Ances, Beau M. Balls-Berry, Joyce E. Bateman, Randall J. Benzinger, Tammie L. Brett, Thomas J. Campbell, Meghan C. Cirrito, John R. Colonna, Marco. Cruchaga, Carlos Davis, Albert A. (Gus) Diantonio, Aaron Gordon, Brian Harari, Oscar Hassenstab, Jason J. Head, Denise P. Hershey, Tamara G. Holtzman, David M. Hudson, Darrell L. Jackrel, Meredith Karch, Celeste M. Kipnis, Jonathan Lucey, Brendan P. McDade, Eric M. Miller, Timothy M. Morris, John Morrow-Howell, Nancy L. Musiek, Erik S. Pappu, Rohit V. Perrin, Richard J. Piccio, Laura Schindler, Suzanne E. Snider, Barbara J. Sotiras, Aristeidis Stark, Susan L. Weihl, Conrad Xiong, Chengjie Yoo, Andrew Zacks, Jeffrey M. Not included on the list
Please enter your mentor no. 2 name (Last Name, First Name) * If you are proposing a mentor who is not listed, he or she would need to be approved by NIH prior to the trainee being appointed to the training program which might create a delay or the request might be rejected by NIH.
* must provide value
Collaborator No. 1 (Please type Lastname, Firstname)
Collaborator No. 2 (Please type Lastname, Firstname)
Collaborator No. 3 (Please type Lastname, Firstname)
Collaborator No. 4 (Please type Lastname, Firstname)
Collaborator No. 5 (Please type Lastname, Firstname)
The applicant NIH biosketch or CV upload.
Please see NIH biosketch guidelines.
The file name format should follow; "NeurologyT32_ApplicantBiosketch_Applicant last name_First name"
* must provide value
Please upload one letter of recommendation.
*The recommendation letter should be from your current mentor .
The file name format should follow; "NeurologyT32_RecommendationLetters_Applicant last name_First name"
* must provide value
Please upload your Personal Statement
Describe your interest in Alzheimer's Disease and Related Dementias ( ADRD) research and your specific training goals (1-page limit)
The file name format should follow; "NeurologyT32_Personal_Statement_Applicant last name_First name"
* must provide value
Please upload your Project Proposal (1-page limit)
The file name format should follow; "NeurologyT32_ProjectProposal_Applicant last name_First name"
* must provide value
The mentor NIH biosketch upload.
Please see NIH biosketch guidelines.
The file name format should follow; "NeurologyT32_MentorBiosketch_Applicant last name_First name"
* must provide value
Survey completion indicates the individual's certification that the statements made therein are true.
* must provide value
Yes, complete the survey.
Submit
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