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* 1. JHED ID

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* 2. PI Name

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* 3. Degrees

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* 4. Academic title

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* 5. School - Primary Appointment

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* 6. Department

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* 7. e-mail

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* 8. Financial Administrator's name

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* 9. Financial Administrator's e-mail

The JHU CFAR is committed to improving the representation of underrepresented minorities, women, and LGBTQIA faculty within the CFAR as it relates to career development activities, leadership opportunities, and faculty recruitment. In order to evaluate our progress, we appreciate your cooperation in completing the following questions. All responses will be kept confidential and used in the aggregate.

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* 10. Current Gender

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* 11. Sex assigned at birth on original birth certificate

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* 12. What is your racial background?
*Please select all boxes with which you identify.

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* 13. What is your ethnicity?

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* 14. Do you have a disability?
Defined as those with a physical or mental impairment that substantially limits one or more major life activities, as described in the Americans with Disabilities Act of 1990, as amended.  See NSF data.

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* 15. Do you come from a Disadvantaged Background?
Individuals from Disadvantaged Backgrounds: if individual meets two or more of the following criteria:
1) Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act (Definition);
2) Were or currently are in the foster care system, as defined by the Administration for Children and Families (Definition);
3) Were eligible for the Federal Free and Reduced Lunch Program for two or more years (Definition);
4) Have/had no parents or legal guardians who completed a bachelor’s degree (see);
5) Were or currently are eligible for Federal Pell grants (Definition);
6) Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child (Definition).
7) Grew up in one of the following areas: a) a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural Health Grants Eligibility Analyzer, or b) a Centers for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage Areas. Only one of the two possibilities in #7 can be used as a criterion for the disadvantaged background definition.

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* 16. Project Title

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* 17. Mentor/Co-Is

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* 18. Location of the Project
International Studies will require NIH clearance

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* 19. Description of Project

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* 20. Purpose of Requested Support

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* 21. If research is currently funded, please list funding entity

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* 22. If currently funded by NIH, list the grant number

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* 23. Description of requested support. Describe how this small grant will help you acquire future funding if appropriate.

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* 24. Does the project involve Human Subjects?
https://grants.nih.gov/policy-and-compliance/policy-topics/human-subjects/hs-decision

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* 25. Does this study involve vertebrate animals?

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* 26. Are you using existing data or specimens?

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* 27. If yes, is it de-identified?

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* 28. Will you have access to subject identifiers?

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* 29. Budget requested

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* 30. Budget Breakdown:

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* 31. Please upload a copy of your biosketch in PDF format.

PDF file types only.