Fellowship Number
Total Project Period
From:
Fellowship Final Report
Through:
Period Reported on:
From:
Through:
1. TITLE OF RESEARCH TRAINING PROPOSAL
2b. FELLOW’S E-MAIL ADDRESS
2a. FELLOW (Name and address, street, city, state, zip code)
2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
2d. MAJOR SUBDIVISION
3a. NAME OF SPONSOR
3b. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3c. TITLE OF SPONSOR
3d. MAJOR SUBDIVISION
3e. SPONSOR’S PHONE NUMBER
3e. SPONSOR’S E-MAIL ADDRESS
4. SPONSORING INSTITUTION (Name and address, street, city, state, 6a. TITLE AND ADDRESS OF OFFICIAL IN SPONSORING
INSTITUTION BUSINESS OFFICE
zip code)
5. ENTITY IDENTIFICATION
NO.
7. HUMAN SUBJECTS
NO
YES
7a. Research Exempt
NO
6b. E-MAIL ADDRESS:
8. VERTEBRATE ANIMALS
If Exempt ("Yes" in 7a):
Exemption No.
YES
If Not Exempt ("No" in 7a):
IRB approval date
8a. If “Yes,”
IACUC approval date
NO
YES
8b. Animal welfare assurance no.
Full IRB or
Expedited Review
7b. Human Subjects Assurance
No.
7c. NIH Defined Phase III Clinical
Trial
NO
9. TRAINING SITE(S) (Organizations and addresses)
YES
10. NAME AND TITLE OF OFFICIAL SIGNING FOR APPLICANT
ORGANIZATION (Item 14)
NAME
11. FELLOW’S TELEPHONE INFORMATION
TITLE
OFFICE
TEL
FAX
E-MAIL
FAX
HOME
Please check here if any of the above information has changed since your initial application.
13. CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete, and accurate to the best of my knowledge.
SIGNATURE OF FELLOW NAMED IN ITEM 2.
DATE
14. SPONSOR AND SPONSORING ORGANIZATION CERTIFICATION AND ACCEPTANCE: We, the undersigned, certify that the statements herein
are true, complete, and accurate to the best of our knowledge.
SIGNATURE OF SPONSOR NAMED IN 3 (In DATE
ink. “Per” signature not acceptable.)
SIGNATURE OF OFFICIAL NAMED IN 10.
(In ink. “Per” signature not acceptable.)
Page 1 of 4
DATE
LRF Individual Fellowship Final Report
15a. PERMANENT MAILING ADDRESS OF FELLOW (Street, city, state,
zip code)
FELLOWSHIP NUMBER
15b. PERMANENT PHONE NUMBER
16. Human subjects and vertebrate animals – Indicate changes since initial application.
A. Human Subjects (Complete Item 7 on the Face Page)
Use of Human Subjects
Change
No Change Since Previous Submission
IRB approval of change
B. Vertebrate Animals (Complete Item 8 on the Face Page)
Use of Vertebrate Animals
Change
No Change Since Previous Submission
IACUC approval of change
17. SUMMARY OF ACTIVITIES (Use continuation pages. Do not exceed 3 pages in addition to this form, not including references.
Any graphs, tables or figures should be appended as a separate document.)
A. CHANGES
Since submission of the last application/progress report, have any significant changes occurred in the research project, academic status, or
time distribution of activities (i.e., percentage of time devoted to research project, course work, teaching, etc.)? If so, explain. Describe any
changes in the specific aims of your project and provide a brief description of any new methodology that has been used to complete the
project.
B. PROGRESS
Describe concisely the research performed and research training obtained during the past year. List all courses taken.
C. CONCLUSIONS AND PLANS FOR FURTHER RESEARCH: Please briefly discuss the results of your project and your plans for further
research in this area.
C. PUBLICATIONS: For each publication resulting directly from the grant and not previously submitted, provide a link to a publicly available online journal or the NIH PubMed Central (PMC) submission identification number. One copy of the publication may be provided if an on-line link
or PMC number is not yet available. List the complete citation. Do not submit manuscripts that have not been accepted for publication. State if
there have been no publications.
E. PROJECT-GENERATED RESOURCES: If the research supported by this grant resulted in data, research materials (such as cell lines, DNA
probes, animal models), protocols, software, or other information available to be shared with other investigators, describe the resource and how
it may be accessed. If the PI is a member of the MCLC, any cell lines must be made available to the MCLC cell-bank. Any patents or other
exclusive resources generated should also be indicated.
F. FUTURE PLANS: Briefly describe your plans for the continued development of your career as a lymphoma researcher. If you have been
appointed to a faculty position at your current or another institution, please provide us with your new contact information.
Page 2 of 4
Name of Applicant (Last, first, middle):
Lay Summary:
Please give a brief summary of the results of your research project, worded so that the average reader of a daily newspaper could
easily understand it:
Page 3 of 4
FELLOWSHIP NUMBER
LRF Individual Fellowship Final Report
(To be completed by sponsor )
19. COMMENTS OF SPONSOR (Use up to one additional page, if necessary)
Evaluate the quality of the training (including academic work) and research progress made by the fellow during the past year. Include
performance on cumulative and qualifying examinations, if applicable.
Page 4 of 4