Form NIH 2674-1 Nih Loan Repayment Programs Applicant Information

Form NIH2674-1 is a U.S. Department of Health and Human Services - National Institutes of Health form also known as the "Nih Loan Repayment Programs Applicant Information". The latest edition of the form was released in May 1, 2014 and is available for digital filing.

Download a fillable PDF version of the Form NIH2674-1 down below or find it on U.S. Department of Health and Human Services - National Institutes of Health Forms website.

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CAUTION:
IF YOU ARE USING A PUBLIC ACCESS
COMPUTER, (I.E., PUBLIC LIBRARY, ETC.)
BE CERTAIN YOU DRAG THIS FORM TO THE TRASH CAN
AND EMPTY THE TRASH WHEN FINISHED.
THIS WILL PREVENT UNAUTHORIZED
ACCESS TO PERSONAL INFORMATION SUCH AS
YOUR NAME, HOME ADDRESS, AND
SOCIAL SECURITY NUMBER.
CAUTION:
IF YOU ARE USING A PUBLIC ACCESS
COMPUTER, (I.E., PUBLIC LIBRARY, ETC.)
BE CERTAIN YOU DRAG THIS FORM TO THE TRASH CAN
AND EMPTY THE TRASH WHEN FINISHED.
THIS WILL PREVENT UNAUTHORIZED
ACCESS TO PERSONAL INFORMATION SUCH AS
YOUR NAME, HOME ADDRESS, AND
SOCIAL SECURITY NUMBER.
OMB No. 0925-0361
Form approved for use through 11/30/2001
Applicant’s Instructions:
U.S. Department of Health and Human Services
Please complete all sections of this form. Attach a copy of your
National Institutes of Health
curriculum vitae (see reverse for requirements), your personal statement,
NIH Loan Repayment Programs
your loan data verification form(s), and your signed contract. See reverse
for detailed instructions.
Applicant Information
Send this package to the National Institutes of Health Loan
Repayment Programs, Federal Building, Room 604, Bethesda,
Maryland 20892- 9121.
1. Applicant’s Name (Last, first, middle)
1a. Other Names Used (e.g., maiden) (Last, first, middle)
2. Professional Degree(s) (If you have a Ph.D., you must attach your
3. Social Security No. (Giving your Social Security number (SSN) is
dissertation abstract.)
voluntary; however, it is necessary for processing your application. If
we do not have your SSN, we cannot process your application.
Please see the Privacy Act information in this package.)
4. Indicate the NIH loan repayment program you are applying to
5a. Do you owe a service obligation to a Federal, State, or other entity?
(See reverse.)
General Research Loan Repayment Program
AIDS Research Loan Repayment Program
No. (Skip to Item 6.)
Clinical Research Loan Repayment Program for individuals from
Yes. (Go to Item 5b.)
Disadvantaged Backgrounds (See reverse for eligibility
restrictions and special instructions.)
5b. Name and address of the program
5c.
5d. Give the date you expect to fulfill the obligation. If the
Name and phone number (including area code) of individual representing the program
obligation is deferred, attach a copy of the letter of
deferment.
6. Anticipated NIH Start Date (See reverse.)
7. Completion of this item is VOLUNTARY; the information provided will be used
to measure the extent to which members of these groups are applying for and
receiving NIH Loan Repayment Program contracts. Failure to answer this
8. Certification of Nondelinquent Status
question will have no effect on your consideration for these programs.
The Federal Debt Collection Procedures Act of 1990 precludes a debtor
a:
c: (Select one or more)
Female
Male
who has a Federal judgment lien against his/her property arising from a
American Indian or Alaska
Federal debt from receiving Federal funds until the judgment is paid in full
or otherwise satisfied. Applicants for the NIH Loan Repayment Programs
Native
b:
Hispanic or Latino
must certify that they do not have a judgment lien against their property
Asian
arising from a debt to the United States.
Not Hispanic or Latino
I hereby certify that I [do
] [do not
] have a judgment lien
Black or African American
against my property arising from a debt to the United States.
Native Hawaiian or
other Pacific Islander
I hereby certify that I [am
] [am not
] delinquent on any debt to
the United States.
White
9. Certification. I certify that the information given in this
Code, Title 18, Section 1001. I am aware that any false, fraudu-
application is true, complete, and accurate to the best of my
lent, or fictitious statement may, in addition to other remedies avail-
knowledge and does not omit any material fact which would
able to the Government, subject me to civil penalties under the
render the statement false, fictitious, or fraudulent as a result
Program Fraud Civil Remedies Act of 1986.
of the omission. I understand that the information given may
be investigated and that any false representation is sufficient
I authorize the program named in Item 5 to release information
cause for rejection of this application, or, if awarded loan
about my service obligation to administrators of the NIH Loan
repayment, that I am liable for return of all awarded funds and,
Repayment Programs, and to other authorized Government offi-
further, that any false statement may be punished as a felony
cials.
under U.S.
Signature (Sign your full name in ink.)
Date
NIH 2674-1 (Rev. 5/14)
PAGE 1 (FRONT)
Privacy Act
09-25-0165
Public reporting for this collection of information is estimated to average 30 minutes, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information, unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to NIH, Project Clearance Office, 6701 Rockledge Drive, MSC
7730, Bethesda, MD 20892-7730, Attention: PRA (0925-0361). Do not return the completed form to this address.
Application Instructions for the
National Institutes of Health (NIH) Loan
Repayment Programs (LRP)
The “Applicant Information” form (NIH 2674-1, pages 1-2), “Loan Data
Applicants to the AIDS Research Loan Repayment Program must also
Verification” form(s) (NIH 2674-2), “NIH Loan Repayment Programs
submit the “ICD Recommendation: Proposed Research Assignment” form
Contract” (NIH 2674-4), and their required attachments should be com-
(NIH 2674-3, page 2) inconsultation with their employing Institute, Center, or
pleted and sent directly to the National Institutes of Health Loan Re-
Division (ICD) and NIH research advisor/supervisor. The NIH may only
payment Programs, Federal Building, Room 604, Bethesda, Maryland
consider applications of individuals who have received a two-year minimum
20892-9121. Individuals are also responsible for ensuring that three
employment commitment or three-year employment commitment for the
references each complete an “Evaluation and Recommendation” form
General Research LRP to conduct qualified research as NIH employees.
(NIH 2674-1, page 3) and send them directly to the LRP at the address
Individuals may consult the LRP InfoLine at 800-528- 7689 for further
above (envelopes are provided in this package.)
information, assistance, and NIH ICD representatives.
Instructions for Form NIH 2674-1 (Revised 5/14)
Curriculum Vitae (C.V.) Requirements
5a. Service Obligation
.
C.V.’s should include the following:
Enter yes or no as to whether or not you currently owe a service
obligation to a Federal, State, or other entity.The following are
Identification and contact information, which includes your
.
examples of programs requiring service obligations:
name, home address, home and work phone numbers, and
citizenship status.
Physicians Shortage Area Scholarship Programs (Federal or
.
.
State)
Education and professional training information such as
.
undergraduate, graduate, and medical; internship, residency,
National Research Service Award Program
.
subspecialty, and other postdoctoral fellowships or training
Public Health Service Scholarship Program
.
programs attended and completed, including the name of the
National Health Service Corps Scholarship Program
institution; the periods of attendance or participation; degrees,
Armed Forces (Army, Navy, or Air Force) Health Professions
.
board eligibility and certifications and credentials received; and
Scholarship Program
.
any professional positions held prior to duty at NIH.
Indian Health Service Scholarship Program
Description of previous research or laboratory experience, includ-
Individuals with obligations under these programs (including mon-
.
ing dates, time spent, name of preceptor, and the research area
etary penalties resulting from failure to serve as required) are in-
Publications, if any.
eligible for the LRP until these obligations are satisfied or unless
their service obligation has been deferred by the appropriate Fed-
Item (Items not listed are considered to be self-explanatory.)
eral, State, or other entity for the period of their service obligation
to the LRP.
2.
Professional Degree(s)
Enter all post baccalaureate degrees (i.e., M.D., Ph.D., M.P.H.).
No loan will be repaid under the LRP which will have the effect of
If you have a Ph.D., you must attach your dissertation abstract.
eliminating any service obligation, or which conflicts with an ex-
isting service obligation.
3.
Social Security Number
The Social Security number (SSN) is required to identify appli-
5c. Name and Phone Number of Individual Representing the Pro-
cants who are selected for LRP contracts to the U.S. Depart-
gram
ment of the Treasury, Internal Revenue Service, for the pay-
Enter the name and telephone number of the program official
ment of Federal income tax on LRP funds paid to your lenders.
who can confirm the nature of your obligation.
(See Privacy Act Notification Statement in this package.) Your
SSN is used for identification purposes only.
5d. Date of Service Satisfaction
Enter the date that you will satisfy your obligation or, if deferred,
4.
Clinical Research LRP
provide a copy of a letter of deferment which indicates the defer-
Only individuals from disadvantaged backgrounds are eligible
ment period.
for the Clinical Research LRP. An individual from a disadvan-
taged background (42 CFR Part 57.1804[c]) is one who:
6.
Anticipated NIH Start Date
Indicate the date you will be able to start working at NIH, the en-
(1) Comes from an environment that inhibited the individual
ter-on-duty (EOD) date stated in your offer of employment from
from obtaining the knowledge, skill, and ability required to
the Personnel Office, or your actual EOD date if you have already
enroll in and graduate from a health professions school; or
commenced NIH employment. Note that the two-year or three-
(2) Comes from a family with an annual income below a level
year minimum service requirement and the determination of ben-
based on low-income thresholds according to family size
efits both begin as of the program eligibility date, the date by
published by the U.S. Bureau of the Census, adjusted an-
which the Secretary, HHS, executes your contract and you begin
nually for changes in the Consumer Price Index, and ad-
a qualified research assignment as an NIH employee.
justed by the Secretary for use in all health professions pro-
grams. The Secretary periodically publishes these income
7.
Gender/Race/Ethnicity (Voluntary)
levels in the Federal Register.
Completion of this item is VOLUNTARY. Failure to answer this
An individual must certify disadvantaged status under the above
question will have no effect on your consideration for this pro-
definition by submitting the following with this form:
gram. This information will be used only for purposes of identify-
ing the number of applications received from and contracts
(1) written statement from the individual’s former health profes-
awarded to individuals from these groups.
sions school(s) that he/she qualified for Federal disadvantaged
assistance during attendance; OR (2) a personal statement ex-
9.
Certification
plaining the applicability of the above definition to his/her cir-
Your application cannot be considered unless this Certification is
cumstances. Current financial need alone is NOT sufficient to
signed and dated.
classify an individual as being from a disadvantaged background.
NIH 2674-1 (Rev. 5/14)
PAGE 1 (BACK)
OMB No. 0925-0361
Form approved for use through 11/30/2001
Applicant’s Name (Last, first, middle)
U.S. Department of Health and Human Services
National Institutes of Health
Applicant’s Instructions:
NIH Loan Repayment Programs
A. Using the space provided below and on the reverse, answer the
.
following questions:
Applicant Information:
.
What are your career goals?
Personal Statement
What are your research and academic objectives?
B. This form must be typewritten.
(continued on reverse)
NIH 2674-1 (Rev. 5/14)
PAGE 2 (FRONT)
Public reporting for this collection of information is estimated to average 60 minutes, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information, unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to NIH, Project Clearance Office, 6701 Rockledge Drive, MSC 7730, Bethesda, MD 20892-7730, Attention: PRA (0925-0361). Do not return the
completed form to this address.
NIH Loan Repayment Programs
Applicant Information:
Personal Statement
(continued)
NIH 2674-1 (Rev. 5/14)
PAGE 2 (BACK)

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