CCTSI PreK Intent to Apply

Applicant Information First Name** Last Name** Email**

If other degree, please specify.

If other affiliation, please specify.

Academic Rank**

If other academic rank, please specify.

University ID

Academic/Position Title**(eg. Chair, Vice Chair, Director, Section Head, Dean, etc.)

School, Center or Institution**Enter N/A if not applicable.

Primary Department**Enter N/A if not applicable.

Division**Enter N/A if not applicable.

Demographic Information

Data collected here are always presented in a de-identified form, predominantly only in aggregate, and customarily only to organizations with a need-to-know status like the National Institutes of Health and the National Science Foundation (typically in conjunction with applications for funding).As our future funding depends on inclusion of diversity, we encourage you to fill out the demographic questions

Gender

If you chose to self-describle, please specify.

Raceselect all that apply

Ethnicity

This applicant has a physical or mental impairment that substantially limits one or more major life activities?

Yes No Prefer not to answer

This applicant comes from a family with annual income below established low-income thresholds

Yes No Prefer not to answer

This applicant is first-generation to college

Yes No Prefer not to answer

This applicant comes from a challenging social, cultural, or educational environment (such as that found in certain rural or inner-city environments that have demonstrably and recently directly inhibited the applicant from obtaining knowledge, skills, and abilities necessary to develop and participate in a research career)

Yes No Prefer not to answer

Mentor Information

You are required to have information for at least one mentor. Information for a second mentor is optional. You are required to have information for at least one mentor. Information for a second mentor is optional. In order to get the most out of this program we require participants to have their proposals pre-reviewed by their mentor (or mentoring team).

Primary Mentor First Name**	Primary Mentor Last Name**	Primary Mentor Email Address**

Other Mentor First Name	Other Mentor Last Name	Other Mentor Email Address

Application Information

Please rate the degree to which your mentoring team has provided assistance in developing this application.**

Not at all A little Somewhat A lot

Is the grant that you are submitting for CCTSI PreK review a:**

New submission (not previously reviewed by a funding agency)
Resubmission (previously reviewed by a funding agency)

Has the grant you are submitting been previously reviewed in the CCTSI PreK program?**

Yes No

Do you currently hold a career development award (such as a K award or professional society award)? **

Yes No

Grant Mechanism**

If Other grant mechanism, please specify

NIH Institute**(or name of other funding agency) Title**(50 words or less) Number of words remaining

Type of research** (select all that apply)

Application Documents

Document requirements:

Adobe .pdf format.
Make sure your Abstract document is named in the following format: LastName_FirstName_PreK_Abstract
Make sure your Specific aims document is named in the following format: LastName_FirstName_PreK_Aims

Use the [Browse] button to locate files on your desktop.

Abstract document** Specific aims document**

Suggested reviewers for your application

Names and email of 3 potential reviewers. Applicants are strongly encouraged to contact reviewers in advance to increase likelihood of their participation.

Potential reviewers cannot not be involved with your application. For example, Mentors, Co-Mentors, and advisors cannot be named as potential reviewers. Applicants are expected to review the career development section of another applicant's grant assigned to the same one hour review block.

First Reviewer First Name**	First Reviewer Last Name**	First Reviewer Email Address**

Second Reviewer First Name**	Second Reviewer Last Name**	Second Reviewer Email Address**

Third Reviewer First Name**	Third Reviewer Last Name**	Third Reviewer Email Address**

Comments Please let us know if you have any questions or comments. (500 characters max)

Problems contact CCTSI Education, Training and Career Development Administration
Email: CCTSI Education, Training and Career Development Administration