AAMHRS
MENTEE APPLICATION FORM
PERSONAL INFORMATION
First Name:
Last Name:
Current Position:
(ex. postdoc fellow, research
associate, assistant professor)
University/Organization:
Address:
City:
State:   Zip Code:  
Phone:    Extension:   
E-Mail:
Gender: Male Female   Age:  
Race/Ethnicity:

PROFESSIONAL INFORMATION
1. Education
University/ School Major/ Area of Study Degree Year
 
 
 
 
2. What is your academic rank?
Are you:  
  tenured? Yes No
  on soft funds? Yes No
  in a post doctoral position? Yes No
  in an academic position? Yes No
  not formally employed? Yes No
 
3. Please list recent research projects in which you have participated:
Year Amount Funding Source Project Name Your Role
 
 
 
 
4. Briefly describe your current research.
5. Have you ever submitted a grant application to NIMH?
     Yes (if "Yes", Date Submitted: )
    No (If no, proceed to No. 8)
6. If yes, what mechanism was used?
RO1 RO3
  K Award B-Start
  R21/R24 Other
  What was the grant assignment number: (e.g., RO1, MH39465-01)
7. Did you receive a priority score?
Yes (if "Yes", what was the score? )
  No (Was it unscored? Yes No)
If "No", have you resubmitted? Yes No
If "No", are you willing to resubmit? Yes No
8. Have you ever been awarded a National Institutes of Health (ex. NIMH, NICHD, NIDA) grant?
     Yes No
9. Please list your publications
Publications
 
 
 
 
10. Please write a 3-page narrative which summarizes the project you would like to submit in a grant application to NIMH. Please email your "Statement of the Proposed Project" as a MS Word document to the coordinator (aamhrs@gmail.com) naming your file accordingly: applicantlastname-statement.doc (ex.: Jones-statement.doc). Your statement must include the following information:
  • Specific Aims of the Research
  • Clear Statement of Research Questions and/or Hypotheses
  • Research Design and Methods
    • Sample Population
    • Research Design (e.g.,Cross-sectional; Longitudinal; Survey; Ethnography; Intervention Study; Clinical Trial)
    • Data Analysis
  • Relevance of the Proposed Work to the Mission and Research Priorities of the National Institutes of Health (Please see http://www.nimh.nih.gov)
11. Please list 3 references
Name Affiliation Email Address
 
 
 
Please ask your references to submit their letter as a MS Word document with the title in the format "applicantslastname-refereeslastname.doc" (Example: Jones-Smith.doc) to the project coordinator at aamhrs@gmail.com.
12. How did you hear about AAMHRS?   
Other (please specify)

13. Please upload your Curriculum Vitae below:



   
Thank you for your interest in our program. If you have questions about the application procedure, please contact:

Center for Research on Rural Families and Communities
Peabody College, Vanderbilt University
230 Appleton Place, Peabody Box 90
Nashville, TN 37203 USA
Phone: (615) 322-6881
Fax: (615) 322-1141
Email: aamhrs@gmail.com aamhrs@gmail.com