Atch 4_RR_PersonalData_1_2-V1.2.pdf

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Research & Related Personal Data D:20061211100028- 05'00' D:20061211100028- 05'00' OMB Number: 4040-0001 Expiration Date: 11/30/2025

RESEARCH & RELATED PERSONAL DATA

Project Director/Principal Investigator and Co-Project Director(s)/Co-Principal Investigator(s) The Federal Government has a continuing commitment to monitor the operation of its review and award processes to identify and address any inequities based on gender, race, ethnicity, or disability of its proposed PDs/PIs and co-PDs/PIs. To gather information needed for this important task, the applicant should submit the requested information for each identified PD/PI and co-PDs/PIs with each proposal. Submission of the requested information is voluntary and is not a precondition of award. However, information not submitted will seriously undermine the statistical validity, and therefore the usefulness, of information received from others. Any individual not wishing to submit some or all the information should check the box provided for this purpose. Upon receipt of the application, this form will be separated from the application. This form will not be duplicated, and it will not be a part of the review process. Data will be confidential.

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

Gender:

Race (check all that apply):

American Indian or Alaska Native Black or African American Native Hawaiian or Other Pacific Islander Do Not Wish to Provide White Asian Ethnicity:

Disability Status (check all that apply):

Visual Other Mobility/Orthopedic Impairment None Hearing Do Not Wish to Provide Citizenship:

Prefix:

* First Name:

Middle Name:

* Last Name:

Suffix:

Gender:

Race (check all that apply):

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Do Not Wish to Provide Ethnicity:

Disability Status (check all that apply):

Hearing Visual Mobility/Orthopedic Impairment Other None Do Not Wish to Provide Citizenship:

RESEARCH & RELATED PERSONAL DATA

Project Director/Principal Investigator and Co-Project Director(s)/Co-Principal Investigator(s) The Federal Government has a continuing commitment to monitor the operation of its review and award processes to identify and address any inequities based on gender, race, ethnicity, or disability of its proposed PDs/PIs and co-PDs/PIs. To gather information needed for this important task, the applicant should submit the requested information for each identified PD/PI and co-PDs/PIs with each proposal. Submission of the requested information is voluntary and is not a precondition of award. However, information not submitted will seriously undermine the statistical validity, and therefore the usefulness, of information received from others. Any individual not wishing to submit some or all the information should check the box provided for this purpose. Upon receipt of the application, this form will be separated from the application. This form will not be duplicated, and it will not be a part of the review process. Data will be confidential.

Prefix: Enter the prefix (e.g., Mr., Mrs., Rev.) for the name of the PD/PI.

First Name: Enter the first (given) name of the PD/PI. This field is required.

Middle Name: Enter the middle name of the PD/PI.

Last Name: Enter the last (family) name of the PD/PI. This field is required.

Suffix: Enter the suffix (e.g., Jr, Sr, PhD) for the name of the PD/PI.

Choose one or more.

American Indian or Alaska Native: A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam. (Note, individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collection strategies.)

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.:

Race (check all that apply) - Asian:

Choose one or more.

American Indian or Alaska Native: A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam. (Note, individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collection strategies.)

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.:

Race (check all that apply) - Black or African American:

Choose one or more.

American Indian or Alaska Native: A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam. (Note, individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collection strategies.)

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.:

Race (check all that apply) - Native Hawaiian or Other Pacific Islander:

Choose one or more.

American Indian or Alaska Native: A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam. (Note, individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collection strategies.)

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.:

Race (check all that apply) - White:

Choose one or more.

American Indian or Alaska Native: A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam. (Note, individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collection strategies.)

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.:

Race (check all that apply) - Do Not Wish to Provide:

Choose one or more.

American Indian or Alaska Native: A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam. (Note, individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collection strategies.)

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.:

Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.: