Applicant's name
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Yes
No
Has your name ever changed?
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Yes No
Please list all previous names
What name will you use for research publications in the future?
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What is your ORCiD ID (To learn more, please visit https://orcid.org/):
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What is your gender?
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Male
Female
I choose not to respond
What is your birth year?
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What is your racial background?
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American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
Caucasian
More Than One Race
Unknown
I Prefer Not to Report my Race
Are you Hispanic or Latino/Latina?
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No
Yes
I Prefer Not to Report my Ethnicity
What is your citizenship status?
(You are required to be a US citizen or have permanent resident status in the United States to be eligible for this grant- to ensure eligibility, please contact the ICTS)
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US Citizen or US Non-Citizen National
Permanent Resident of the US
Other
If other, please describe
What is your primary contact telephone number?
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What is your secondary contact telephone number?
What is your work email address?
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What is your personal email address?
Program applying to
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ICTS TL1 Program
ICTS KL2 Program
What is your current degree?
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MS/MA
PhD
MD
MD/PhD
Other
If other, please describe
What is your primary department?
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Do you belong to a secondary department?
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Yes No
If yes, please list secondary department
What is your proposed project title?
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What is your research area?
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What is your primary mentor's name?
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Primary mentor's department
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Primary mentor's telephone number
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Primary mentor's email address
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Do you have a secondary mentor?
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Yes No
If yes, secondary mentor's name
If yes, secondary mentor's department
If yes, secondary mentor's telephone number
If yes, secondary mentor's email address
What percentage of your time is spent in research activities? (if you do not perform this activity, please leave at 0 percent)
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What percentage of your time is spent in clinical activities? (if you do not perform this activity, please leave at 0 percent)
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What percentage of your time is spent in teaching activities? (if you do not perform this activity, please leave at 0 percent)
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Have you ever published in a peer-reviewed journal?
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Yes No
Have you ever been a recipient of any research grants?
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Yes No
Have you participated in running or directing a Clinical Trial?* (see definition below)
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Yes No
*clinical trial is defined as a research study in which one or more human participants are prospectively assigned to one or more interventions (which may include placebo or other control) to evaluate the effects of those interventions on health-related biomedical or behavioral outcomes.
If yes, please provide IRB approval number(s)
Have you participated in any of the following review activities? (please check all that apply)
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If other, please describe
Have you participated in any of the following technology transfer activities? (please check all that apply)
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If other, please describe
Have you ever been an author or co-author on any presentations at national or international meetings related to your research?
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Yes No
If your study meets the NIH definition of a clinical trial it must pass through an extra stage of scrutiny from the NIH before we are able to distribute your research funds. If you are proposing a clinical trial, please expect that your documents (IRB protocol and related human subjects protections documents) will be carefully examined for clarity, consistency, and scientific rigor. This process often leads to delays in the release of research funds from NIH. Please note that if you answer "yes" to the following 4 questions then your study meets the definition of a clinical trial and will require a high level of regulatory oversight. If the answer is "Yes", please check the box (check all that apply)
If you will be conducting human subject's research, what is the status of your IRB application?
Pending
Approved
N/A
If you will be conducting animal subject's research, what is the status of your IACUC application?
Pending
Approved
N/A
IACUC number, if approved
All NIH training awards require that trainees be certified in the Responsible Conduct of Research. I agree that if funded, I will complete the Responsible Conduct of Research training by participating in the ICTS RCR course.
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I agree I do not agree
All NIH grants require that awardees are tracked on specific metrics for 10 years post-award. I agree that if funded, I will complete all annual NIH survey follow-ups as part of receipt of this award.
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I agree I do not agree
If awarded, all manuscripts published associated with this grant must be made public-access compliant as dictated by NIH policy. If awarded, I agree to abide by NIH public-access compliance and report any manuscript that was supported by this grant.
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I agree I do not agree
Please upload your Research Plan (5 pages):
Project Title, Key Words, Research Abstract (1/2 page) Specific Aims and Hypothesis (1/2 page) Background and Significance (1 pages) Preliminary Studies (1 page) Research Design and Methods (2 pages) Address rigor and reproducibility Describe consideration of relevant biological variables (ie sex, age weight, and underlying health conditions etc) Include a statistical plan * must provide value
Please upload your Career Development and Mentorship Plan (2 pages):
Candidate Statement of research career goals Mentorship Plan including: Extent of the supervision provided Communication Plan Any specific courses and training proposed * must provide value
Please upload your Timeline (1 page):
Include publication plan and grant submission plan * must provide value
Please upload your Applicant NIH Bio-Sketch:
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Please upload your Mentor 1 Letter:
Outline the qualification of the applicant and the availability of resources for the applicant to complete their research Statement regarding the mentors role in career development of the ICTS KL2 scholar. It should be stressed that primary review criteria include the extent of support provided by the mentor/department and the quality of mentoring. * must provide value
Please upload your Mentor 1 Bio-Sketch:
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Please upload your Mentor 2 Letter:
Outline the qualification of the applicant and the availability of resources for the applicant to complete their research Statement regarding the mentors role in career development of the ICTS KL2 scholar. It should be stressed that primary review criteria include the extent of support provided by the mentor/department and the quality of mentoring. * must provide value
Please upload your Mentor 2 Bio-Sketch:
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Please upload your Mentor 3 Letter:
Outline the qualification of the applicant and the availability of resources for the applicant to complete their research Statement regarding the mentors role in career development of the ICTS KL2 scholar. It should be stressed that primary review criteria include the extent of support provided by the mentor/department and the quality of mentoring. * must provide value
Please upload your Mentor 3 Bio-Sketch:
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Please upload your signed statement of support from the department chair or division chief:
This letter should address the availability of resources and the departments commitment to allow the applicant 75% release time to perform research. * must provide value
Please combine all pieces of the application (previous PDF's) and upload in one PDF here:
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Submit
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