K12 Research Scholar Awards Application

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

U.S. Citizen or Permanent Resident**

Yes No

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

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

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

Application Information Proposal title**

Keywords**Enter 5 keywords to describe your application. This will help the administrative team determine who needs to review your application.

Type of research** (select all that apply)

Intent Document

Please create one PDF document for uploading into the online application. Required sections should be in the order listed below. Use Arial 11 pt font or larger. Single spaced paragraphs. Page margins no less than 0.5 inches on all four sides.

Face page (K12 template)
Current NIH Biosketch from applicant
Biosketches from each mentor (total two)
Summary of Career Goals (1 page)
Specific Aims page (1 page)

**See the CCTSI K12 Research Scholar Application Information web page for more details.

Document requirements:

Adobe .pdf format
Make sure your document is named in the following format: LastName_FirstName_K12_Intent.

Intent document Use the [Choose File] button to locate files on your desktop.

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

For program related questions regarding your application contact Ellen Burnham, MD, MS Email:Ellen.Burnham@ucdenver.edu
If you have any problems submitting this application or other technical issues contact CCTSI Education and Training Administration Email: CCTSI Education and Training Administration