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1. Name

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2. Email

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3. School/Division

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4. Topic of research plan

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5. Mentor Name (if identified)

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6. If mentor not yet identified, do you need assistance identifying someone?

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7. Where are you currently in the process of developing your research plan?

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8. Do you have a funder (specific NIH institute or non-federal) and/or grant mechanism in mind?

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9. Preferred meeting location

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10. My proposal is a:

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11. Goal submission date

Date

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