NLM Training Program: Trainee Application Form

NLM Training Program: Trainee Application

Name of Institutional Representative contacted:
Level
  • - select an option -
  • Predoctoral
  • Postdoctoral

Applicant

First Name
Middle Name
Last / Family Name
Gender
  • - select a option -
  • Female
  • Male
Ethnicity
Work Email
Private Email (gmail, etc)
Birthdate

Home Address

Address 1
Address 2
City
State
Zip
Work Phone
Cell Phone
Address Valid Until

Citizenship Status

Citizenship
  • - select a option -
  • U.S. Citizen or Dual Citizen
  • Permanent Resident
  • Foreign National with visa
Visa Type
Visa Number
Your Institution
Your Department
Your Primary Mentor / Advisor
Your Mentor / Advisor's Department
Your Mentor / Advisor's Institution
Your Co-Mentor
Your Co-Mentor's Department
Your Co-Mentor's Institution
Please provide information about any Responsible Conduct of Research course you have taken at your current level of training (predoc, postdoc). Include the course number, institution, and date taken. If you have not taken a course during your graduate training or your postdoc, please include plans for this course as part of your mentoring plan (see list under Curriculum).

For Predoctoral Applicants

For predoctoral applicants only: date you started your PhD program
For predoctoral applicants only: month/year you anticipate receiving your PhD degree
For predoctoral applicants only: number of months of full-time research prior to beginning your PhD program
For predoctoral applicants only: number of months of full-time research prior to beginning your PhD program

For Postdoctoral Applicants

Thesis Title
Thesis Advisor
Thesis Advisor Department and Institution

All Applicants

Publications and abstracts to date; please number the items and identify which are abstracts
Institution Attended for PhD
Institution Attended for Master's Degree
Institution Attended for Bachelor's Degree
Other Institution(s) Attended
Field of Study
Field of Study
Degree/ Field of Study
Degree/ Field of Study
Degree Date
Degree Date
Degree Date
Degree Date
GPA
GPA
GPA
GPA

Testing Information

GRE Verbal Raw
GRE Quantitative Raw
GRE Analytical Raw
GRE Verbal Percentile
GRE Quantitative Percentile
GRE Analytical Percentile
TOEFL
Grant Support
Please list any previous fellowship or grant support for the trainee, the funding agency or foundation, and dates of the support.

Mentor Information

Primary Mentor
Co-Mentor
Desired Start Date
Department
Co-Mentor's Department
Institution
Co-Mentor's Institution

Provide 6-8 keywords (most important ones first) describing your research area:

Keyword 1
Keyword 5
Keyword 2
Keyword 6
Keyword 3
Keyword 7
Keyword 4
Keyword 8
Project Title
Domain of Informatics: healthcare/clinical, translational bioinformatics, or clinical research informatics (see NLM home page for descriptions)
Project Description max. 750 words
Layperson's Project Description max. 250 words
This should be a simple description that would be understandable by someone with only basic science background.
It will be used in annual reports to the funding agency.
Career Goals max. 500 words
Describe your overall career goals and how they relate to this program. Describe the education, training and other career development experiences you will need to achieve your career goals, and how this training program will help you achieve them.
Mentoring Plan max. 400 words
Mentoring and Training Plan
Please provide a brief description in your own words of the plan you and your mentor have jointly developed to achieve your fellowship project and your career goals.

We are particularly interested in what specific skills / knowledge you will acquire from both mentors, and how your mentors will collaborate.

Include anticipated didactic course work for your ENTIRE fellowship, the research training you will receive, personal and career development activities (e.g. in writing and speaking skills) in which you will participate, professional meetings you will attend, etc.

The plan should include an estimated timeline for completion of the graduate or postdoctoral training program and specific milestones to be achieved, including publications from this fellowship project.