Application for a Traineeship in Research in Integrative Medicine (T.R.I.M.) Osher Center for Integrative Medicine University of California, San Francisco Please complete the following application and submit per the options below. Whatever submission method you choose, please be sure to confirm that it was received. Application and all correspondence TRIM Program (Attn: Yvette Coulter) should be addressed to: Osher Center for Integrative Medicine By e-mail / pdf coultery@ocim.ucsf.edu Or U.S. Postal Service: Box 1726, San Francisco, CA 94143-1726 Or other delivery (e.g. UPS or FedEx): 1545 Divisadero St., Suite 514, San Francisco, CA 94115 If you have questions call: 415-353-7991 or e-mail: coultery@ocim.ucsf.edu Name & Degree(s): Home Address: Home Telephone: ( ( ) Office Address: Office Telephone: ( ( ) Pager or Mobile (optional): ( ( ) E-mail address: Citizenship: If other than U.S., type of visa: ELIGIBILITY: In order to qualify for this federally funded grant, an applicant must be a U.S. citizen, a non-citizen national or a foreign national possessing a visa permitting permanent U.S. residence. Having a temporary or student visa is not acceptable under this grant. At this time, we are unable to consider applications of any individuals who do not meet the eligibility criteria outlined above. How did you learn about the TRIM program? TRIM Traineeship Application Form - Page 1
Please provide below the names, addresses, titles, and telephone numbers of three individuals whom you have asked to provide recommendations. Letters should provide comment on current and previous stages of your career. References: signed letters must be received by close of business on the application deadline. They may be sent by mail, courier, fax or PDF attachment to e-mail, but must be signed. By filling in the boxes below, you are affirming that the following individuals have been asked to send recommendation letters directly to the TRIM program coordinator at the address above: 1) 3) 2) These people are aware that their recommendation letters must be received by the TRIM program coordinator by the close of business on the application deadline date. Applicant initials: _ Please indicate the graduate and undergraduate institutions from which you have received degrees. Begin with most recent: Degree Institution Location Dates (Mo./Yr.) attended Major If not yet received, enter date doctorate degree is expected: T.R.I.M. post-doctoral fellowships are open to individuals with doctoral degrees (e.g., MD, PhD, DO, ND, etc.). Doctorate degree must be awarded prior to the date applicant would begin the TRIM post-doctoral fellowship program. to to to to TRIM Traineeship Application Form - Page 2
Have you ever received any NRSA stipends? (for information about NRSA funds see this link: http://grants.nih.gov/training/nrsa.htm If so, please describe the program briefly and provide dates of your involvement: _ 1. Personal Statement: Please provide a typewritten statement that includes the following (single spaced, 11 or 12 point font, not to exceed four pages): a. Indications of your commitment to pursue research in integrative medicine. Please include information about any past experience that may show this commitment, b. The training and research experience you hope to obtain, and your career goals. Be as specific as possible. 2. If you have identified one or more faculty members with whom you would like to work, please list name(s) here: 3. Please append one example of your writing. This demonstration of your ability to present scientific findings in written form is one of the most important parts of your application. It can be an article, report, or some other document that you personally wrote. Please submit only material for which you are the first author listed. If you are submitting an unpublished manuscript or section of your dissertation, please limit your submission to 10 single-spaced or 20 double-spaced pages. 4. Curriculum Vita: Please append a recent CV that provides at least the following information: Undergraduate colleges attended, including institution name, location, inclusive dates attended, major and minor discipline(s) studied, and degree received. Graduate or professional schools attended, including Institution name, location, years attended, major discipline(s) studied, and degree received. Postgraduate training, including institution name, location, years attended, major discipline(s) studied, and degree received. Honors and awards, including scholarships. Publications and papers presented at professional meetings. Previous employment, including job title, years worked in the position, and type of work performed. TRIM Traineeship Application Form - Page 3
5. Demographics. Providing the following information is voluntary. There is no penalty for leaving this item blank, however it will be helpful to the Osher Center in evaluating the effectiveness of our outreach and publicity efforts. Please indicate your racial and/or ethnic identity: Do you have a disability? Yes / No NIH Definition: Individuals with disabilities, who are defined as those with a physical or mental impairment that substantially limits one or more major life activities. Are you from a disadvantaged background? Yes/ No NIH Definition: 1. Individuals who come from a family with an annual income below established low-income thresholds. For individuals from low-income backgrounds, the institution must be able to demonstrate that such candidates (a) have qualified for Federal disadvantaged assistance; or (b) have received any of the following student loans: Health Professional Student Loans (HPSL), Loans for Disadvantaged Student Program; or (c) have received scholarships from the U.S. Department of Health and Human Services under the Scholarship for Individuals with Exceptional Financial Need. 2. Individuals who come from a social, cultural, or educational environment such as that found in certain rural or inner-city environments that have demonstrably and recently directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a research career. Please sign below to confirm that all information included on this form, and in any supporting documents submitted as part of your application, is true: Signature Date Please read carefully the information below regarding various requirements of the National Institutes of Health. Please print the entire document and sign the last page to verify that you understand these guidelines will apply to you, if you are accepted to be a Post-doctoral Fellow in the Osher Center s TRIM Program. The Osher Center for Integrative Medicine Training in Research in Integrative Medicine (TRIM) Program University of California, San Francisco P.O. Box 1726 San Francisco, CA 94143-1726 415-353-7700 www.osher.ucsf.edu The Osher Center s T.R.I.M. program is a training program consisting of required seminars and formal course work, individual mentoring, research and creative activity, elective seminars and classes, teaching, and a number of optional activities. TRIM Traineeship Application Form - Page 4
The T.R.I.M. post-doctoral fellowship program is funded by a T-32 Training Grant from the National Center for Complementary and Alternative Medicine (NCCAM), part of the National Institutes of Health (NIH). Programs receiving training funds from the NIH (http://grants.nih.gov/training/nrsa.htm ) must comply with various guidelines and requirements. Participants in the T.R.I.M. program need to be aware of the following important information. Applicants will need to print this document, sign it, and return it with their application materials to verify that they have read and understood the information outlined below. Educational Requirements: Postdoctoral trainees must have received, as of the beginning date of the NRSA appointment, a Ph.D., M.D., D.D.S., or comparable doctoral degree from an accredited domestic or foreign institution. Eligible doctoral degrees include, but are not limited to, the following: D.M.D., D.C., D.O., D.V.M., O.D., D.P.M., Sc.D., Eng.D., Dr. P.H., D.N.Sc., Pharm.D., N.D. (Doctor of Naturopathy), D.S.W., Psy.D, as well as a doctoral degree in nursing research or practice. Documentation by an authorized official of the degree-granting institution certifying all degree requirements have been met prior to the beginning date of the training appointment is required. Trainee Citizenship: At the time of appointment to the training program, individuals selected for research training supported by NRSA institutional training grants must be citizens or non-citizen nationals of the United States, or must have been lawfully admitted to the United States for permanent residence, i.e., in possession of a currently valid Alien Registration Receipt Card I-551, or some other legal verification of legal admission as a permanent resident. Non-citizen nationals are generally persons born in outlying possessions of the United States (e.g., American Samoa and Swains Island). Individuals on temporary or student visas are not eligible for Kirschstein-NRSA support. In addition, trainees must be able to commit full-time effort in the program at the time of appointment. Service Payback: As specified in the NIH Revitalization Act of 1993, Kirschstein-NRSA recipients incur a service payback obligation for the first 12 months of postdoctoral support. Additionally, the Act specifies that the second year of postdoctoral Kirschstein- NRSA training support will serve to pay back a postdoctoral service payback obligation. Service payback obligations can also be paid back after termination of Kirschstein-NRSA support by conducting health-related research or teaching averaging at least 20 hours per week of a full work year. Payback service may be conducted in an academic, governmental, commercial, or nonacademic environment, in the United States or in a foreign country. Examples of acceptable payback service include research associateships/assistantships, postdoctoral research fellowships, and college or high school science teaching positions. Examples of unacceptable payback service include clinical practice and administrative responsibilities not directly related to scientific research. Recipients with service obligations must begin to provide acceptable payback TRIM Traineeship Application Form - Page 5
service on a continuous basis within two years of termination of Kirschstein-NRSA support. The period for undertaking payback service may be delayed for such reasons as temporary disability, completion of residency requirements, or completion of the requirements for a graduate degree. Requests for an extension must be made in writing to the NIH specifying the need for additional time and the length of the required extension. Recipients of Kirschstein-NRSA support are responsible for informing the NIH of changes in status or address. For individuals who fail to fulfill their obligation through service, the United States is entitled to recover the total amount of Kirschstein-NRSA funds paid to the individual for the obligated period plus interest at a rate determined by the Secretary of the Treasury. Financial payback must be completed within three years beginning on the date the United States becomes entitled to recover such amount. Under certain conditions, the Secretary, DHHS (or those delegated this authority), may extend the period for starting service or repayment, permit breaks in service, or in rare cases in which service or financial repayment would constitute an extreme hardship, may waive or suspend the payback obligation of an individual. Detailed information on the accrual and repayment of the Kirschstein-NRSA service payback obligation and waivers is available at: http://grants.nih.gov/training/payback.htm Officials at the grantee institution have the responsibility of explaining the terms of the payback requirements to all prospective trainees before appointment to the training grant. Additionally, all trainees recruited into the training program must be provided with information related to the career options that might be available when they complete the program. The suitability of such career options as methods to satisfy the NRSA service payback obligation must be discussed. Trainee Appointments: All trainees are required to pursue their research training full time, normally defined as 40 hours per week, or as specified by the sponsoring institution in accordance with its own policies. Appointments are normally made in 12-month increments, and no trainee may be appointed for less than 9 months during the initial period of appointment, except with prior approval of the NIH awarding unit, or when trainees are appointed to approved, short-term training positions. No individual trainee may receive more than 5 years of aggregate NRSA support at the predoctoral level or 3 years of support at the postdoctoral level, including any combination of support from institutional training and individual fellowship awards. Any exception to the maximum period of support requires a waiver from the NIH awarding office based on a review of the written justification from the individual trainee, and endorsed by the Program Director and the sponsoring grantee institution. Trainees seeking additional support are strongly advised to consult with the NIH awarding office. TRIM Traineeship Application Form - Page 6
Stipends: The Osher Center for Integrative Medicine is required to compensate post-doctoral participants in the T.R.I.M. program according to the stipend levels approved by the NIH. Years of relevant experience must be calculated post-doctorate. The information below can also be found at this web page: http://grants.nih.gov/grants/guide/notice-files/not-od-10-047.html Ruth L. Kirschstein National Research Service Award (NRSA) Stipend and Other Budgetary Levels Effective for Fiscal Year 2015. Career Level Years of Experience Stipend for FY 2015 Monthly Stipend Postdoctoral 0 $42,840 $3,570 1 $44,556 $3,713 2 $46,344 $3,862 3 $48,192 $4,016 4 $50,112 $4,176 5 $52,116 $4,343 6 $54,216 $4,518 7 or More $56,376 $4,698 Taxability of Stipends: Internal Revenue Code Section 117 applies to the tax treatment of all scholarships and fellowships. The Tax Reform Act of 1986, Public Law 99-514, impacts on the tax liability of all individuals supported under the NRSA program. Under that section, non-degree candidates are now required to report as gross income all stipends and any monies paid on their behalf for course tuition and fees required for attendance. Degree candidates may exclude from gross income (for tax purposes) any amount used for tuition and related expenses such as fees, books, supplies, and equipment required for courses of instruction at a qualified educational organization. The IRS and Treasury Department released regulations in January 2005 (Revenue Procedure 2005-11) clarifying the student exception to the FICA (Social Security and Medicare) taxes for students employed by a school, college, or university where the student is pursuing a course of study. Our understanding is that these final regulations do not apply to or impact Kirschstein-NRSA programs or awards. An NRSA stipend is provided by the NIH as a subsistence allowance for Kirschstein-NRSA fellows and trainees to help defray living expenses during the research training experience. NRSA recipients are not considered employees of the Federal government or the grantee institution for purposes of the award. We must note that NIH takes no position on the status of a particular taxpayer, nor does it have the authority to dispense tax advice. The interpretation and implementation of the tax laws are the domain of the IRS. TRIM Traineeship Application Form - Page 7
Individuals should consult their local IRS office about the applicability of the tax laws to their situation and for information on their tax obligations. Recruitment to Enhance Diversity: In accordance with NIH goals, the Osher Center for Integrative Medicine seeks to diversify student and faculty populations and thus to increase the participation of individuals currently underrepresented in the biomedical, clinical, behavioral, and social sciences such as: individuals from underrepresented racial and ethnic groups, individuals with disabilities, and individuals from socially, culturally, economically, or educationally disadvantaged backgrounds that have inhibited their ability to pursue a career in health-related research. Applicants will be asked to voluntarily provide information regarding their biographical circumstances that might be relevant to these recruitment goals. For more detailed information describing these underrepresented populations, please visit this NIH web page: http://grants1.nih.gov/grants/guide/pa-files/pa-06-468.html#sectionviii and view the section pertinent to recruitment (IV.6). Evaluation and Tracking: Trainees will be asked to remain in touch with program coordinators and the NIH for a 10-year period following completion of the program to aid in determining the success or failure of the program. The program will be deemed successful (by the NIH) based on numbers of people who remain in a research-related profession, especially those actively conducting research in complementary and alternative medicine. I have read and understood the information outlined above.* _ Applicant Name (please print) Signature Date TRIM Traineeship Application Form - Page 8