NTRAIN K12 Combined Application Form

Application Cycle

Last Name

First Name

Previous Last Name (if applicable)

Middle Initial

Date of Birth

Phone Number

Work Address

City

State

Zip Code

Email Address

eRA Commons Username

Academic Title

Department

Institution

Citizenship

Ethnicity

Race

Are you a person with a disability?

Are you a female?

Title of Proposed Research Project:

First Name

Last Name

Academic Title (including Department & Institution)

Email Address

Do you have additional mentors?

First Name

Last Name

Academic Title (including Department & Institution)

Email

Do you have additional mentors?

First Name

Last Name

Academic Title

Email Address

Please provide a personal statement describing your career and research objectives and how your background, experience and training have prepared you for advanced Neurorehabilitation research training (roughly one page). Include one page of specific aims (as for an NIH R01) and up to 5 page description of the research project including significance, innovation and proposed research design. Reference citations do not count as part of the 5 page requirement.

The applicant should identify a primary mentor and potential co-mentors, located either locally or nationally. Members of the NTRAIN Executive Committee are able to provide guidance for identifying potential mentors if needed.

Identify what gaps you see in your training to date and describe how your mentor(s) and training plan will address these gaps. Include a clearly articulated proposed training plan (lab work, coursework, national meetings) for the two years of the K12 scholar program.

Provide two letters of recommendation. One letter of recommendation should be from your primary mentor and the other from another individual familiar with your research accomplishments and potential. These reference letters should be sent directly to Dr. Barbara Bregman at bregmanb@georgetown.edu.

Submit a detailed statement of support from the current institution (usually Department Chair or Dean). This statement should confirm current appointment and the guarantee that the applicant will be able to contribute 75% of full-time effort to this award and the institution will waive F&A funds (facility & administration). Institutional support commitments beyond these two years are strongly encouraged and will be factored into the selection process.

Please list specific disciplines or areas of expertise required among prospective reviewers

NIH Biosketch: please attach your NIH Biosketch(1-5 pages)