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Employer Job Application Sample

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					Revised June 2006


                               INSTRUCTIONS FOR USING THIS WORKBOOK

Use these tables in conjunction with the "Supplemental Instuctions for Preparing an ERC Application"
that are found on the NIOSH Web site at: http://www.cdc.gov/niosh/oep/funding.html#train

For ease in downloading, these tables have been provided as one consolidated excel workbook.

Headers: In the Left Section Header, enter the applicable Program. For example, [ ] Program would be
replaced with OHN Program. [Please note that tables used only once do not have Left Section Headers.]
In the Right Section Header, add the name of the CENTER Director (not the Program Director), e.g.,
Center Director: Lorraine Conroy.

As you may have personnel in different departments completing each of the tables, the individual table
worksheets may either be copied and pasted into a blank excel worksheet for distribution within your
institution, or you may add worksheets to this workbook and copy and paste the tables to the new
worksheets.

You will use tables 1, 2, 3, 14 (if applicable) and 15 (if applicable) just once. Enter your institution and
Center director name in the cells provided at the upper left corner of the table.

You will use tables 4a, 4b, 5, 6, 7, 8, 9, 10 and 13 several times - once for each discipline. In each of
these tables, enter your institution and program director name and the discipline in the cells provided at
the upper left corner of each table.

Tables 11, 12a, 12b, and 12c will be used by OSH CE and HST CE Programs.

Do not delete columns from any of the tables.

NOTE: In reporting aggregate data, do not double-count trainees. Each trainee should only be reported
once per table.
                                                                                                                                  Center Director:



       ERC Applicant Institution:
       Center Director:

                                                                              Table 1
                                                                   ERC Academic Training Programs

                                                                  Number of Faculty       Number of Pre-doctoral Trainees3   Number of Post-
                                                1
                 Approved Academic Program                      Core2        Supporting      F/T                  P/T        doctoral Trainees
Page




       Refer to: Supplemental Instructions, page 7.
       1
         Industrial Hygiene, Occupational Health Nursing, etc.
       2
         F/T faculty member teaching within each academic program.
       3
         Trainee counts include all students in the approved programs.




       Table 1
                                                                                                                                                   Center Director:



       ERC Applicant Institution:
       Center Director:

                                                                Table 2
                      ERC Faculty Members' Research and Training Grant and Contract Support (all Sources of Support)

                                                                                                            Project                             If part of a larger
                                       Active/                                Funding                        Start      Project    Annual      project, identify PI
         Faculty Member Name1         Pending       Grant/Contract Title      Source      Grant Number       Date      End Date Direct Costs     of parent grant2
       IH Program



       OHN Program
Page




       OMR Program



       [Fill in] Program



       [Fill in] Program




       Refer to: Supplemental Instructions, page 8.
       1
         Group core and supporting faculty members by academic program. Only count each faculty member once (with primary program).
       2
         Larger grants, e.g., center grants or program projects..




           Table 2
                                                                                                                                          Center Director:



       ERC Applicant Institution:
       Center Director:
                                                                        Table 3
                                         Current and Past Trainees - Since Beginning of Current Project Period1

                                                                          Train- Train-
                                                                           ing    ing                                                 Current Trainee:
                                                             P     Pre    Start   End                                                Source of Support
           Primary Faculty                                   or    or      Date   Date                                                 Past Trainee:
           Advisor Name2              Trainee Name           C3   Post4   mm/yy mm/yy                    Title of Research Project    Current Position
       IH Program




       OHN Program



       OMR Program
Page




       [Fill in] Program



       [Fill in] Program




       Refer to: Supplemental Instructions, page 8.
       1
         Trainee counts include all students in the approved programs.
       2
         Group faculty members by academic program. Only count each faculty member once (with primary program).
       ³ P = Past, C = Current
       4
         Pre = Pre-doctoral, Post = Post-doctoral




       Table 3
       [ ] Program                                                                                                                                Center Director:



       ERC Applicant Institution:
       Program Director:
       Discipline:
                                                                        Table 4a
                                                               Academic Training Report
                                                   Previous Budget Period: July 1, 200x to June 30, 200x

                                                                                       # Full-Time                    # Part-Time      # Other
                                                                      # Full-Time        NIOSH-         # Part-Time     NIOSH-        Trainees
                                                                       Trainees        Supported         Trainees     Supported     Taking OS&H    # Trainees
           Degree Awarded           How Does Degree Read?              Enrolled1        Trainees          Enrolled     Trainees       Courses2     Graduated
       Baccalaureate/associate degree



       Master's degree
Page




       Doctorate degree




       Post-doctoral (Include formally registered Occupational Medicine residents in all years of the residency.) 3



       Other (specify, e.g., undergraduate Certificate program trainees)




       Refer to: Supplemental Instructions, page 8.
       1
         Trainee counts include all students in the approved programs.
       2
         Does not include trainees counted in any of the full-time or part-time categories
       3
         In this case, there may be double counting between Doctorate degree and Post-doctoral categories.



       Table 4a
       [ ] Program                                                                                                                                Center Director:



       ERC Applicant Institution:
       Program Director:
       Discipline:
                                                                          Table 4b
                                                                  Academic Training Report
                                                           Since Beginning of Current Project Period

                                                                                       # Full-Time                    # Part-Time      # Other
                                                                      # Full-Time        NIOSH-         # Part-Time     NIOSH-        Trainees
                                                                       Trainees        Supported         Trainees     Supported     Taking OS&H    # Trainees
           Degree Awarded           How Does Degree Read?              Enrolled1        Trainees          Enrolled     Trainees       Courses2     Graduated
       Baccalaureate/associate degree



       Master's degree
Page




       Doctorate degree




       Post-doctoral (Include formally registered Occupational Medicine residents in all years of the residency.) 3



       Other (specify, e.g., undergraduate Certificate program trainees)




       Refer to: Supplemental Instructions, page 8.
       1
         Trainee counts include all students in the approved programs.
       2
         Does not include trainees counted in any of the full-time or part-time categories
       3
         In this case, there may be double counting between Doctorate degree and Post-doctoral categories.



       Table 4b
       [ ] Program                                                                                                                   Center Director:



       ERC Applicant Institution:
       Program Director:
       Discipline:
                                                                         Table 5
                                                       Tracking Graduates-Academic Training Report1
                                                         Since Beginning of Current Project Period

                                                                                              Date of
                                                                                          Certificate of                             Employed in
                                                      Date Degree                          Completion                                OS&H Field
                                                       Awarded                            (for Occ Med                                or Enrolled
                                          Date         (only if at                          and other                                  in OS&H
       Trainee Name (if supported       Entered           your       Degree Awarded         Certificate                               Academic
        by a NIOSH training grant,      Program       institution) (also specialty area     programs)      Current Employment (Job    Program?
              denote with *)            (mm/yy)         (mm/yy)    as noted on degree)       (mm/yy)            Title/Employer)           Y/N
       Year 1: July 1, 200x to June 30, 200x
Page




       Year 2: July 1, 200x to June 30, 200x



       Year 3: July 1, 200x to June 30, 200x



       Year 4: July 1, 200x to June 30, 200x




       Refer to: Supplemental Instructions, page 8.
       1
        Graduate counts include all trainees graduated from the approved programs.




           Table 5
       [ ] Program                                                                                                                          Center Director:



       ERC Applicant Institution:
       Program Director:
       Discipline:
                                                                            Table 6
                                                                     Trainee Summary Data
                                                            Since Beginning of Current Project Period

                                                    # Applicants         # Trainees   # Trainees   # Trainees     # Trainees
                                    # Applicants       Offered            Entering     Who Left    Currently in   Completed    # Post Doc    # Post Doc
                         1
                 Level                Applied        Admission            Training2    Program      Training       Training       MDs           PhD
Page




       Refer to: Supplemental Instructions, page 9.
       1
         Masters, doctoral, etc.
       2
         Trainee counts include all students in the approved programs.




       Table 6
       [ ] Program                                                                                                                     Center Director:



       ERC Applicant Institution:
       Program Director:
       Discipline:
                                                                             Table 7
                                                         Trainee Qualifications - Prospective Pre-Doc1
                                                     Previous Budget Period: July 1, 200x to June 30, 200x
           Applicant (Identify by                      Was Applicant Offered   Did Applicant Enter
              Sequential #)         GRE Scores          Admission? (Y/N)         Program? (Y/N)      US Citizen? (Y/N)   Permanent Resident? (Y/N)
Page




       Refer to: Supplemental Instructions, page 9.
       1
        Occ Med residents are not listed here; list them on Table 8.




       Table 7
       [ ] Program                                                                                                               Center Director:



       ERC Applicant Institution
       Program Director:
       Discipline:
                                                                           Table 8
                                                       Trainee Qualifications - Prospective Post-Doc1
                                                   Previous Budget Period: July 1, 200x to June 30, 200x

                                                                                                                Was     Did
                                                                                                               Appli- Appli-
        Applicant                                                                                               cant   cant
        (Identify                                                                                              Offered Enter    US       Perm
            by    Highest  Year                                                                                Admis- Pro-      Citi-    Resi-
        Sequen- Previous Awarded                                                           Previous Residency sion? gram?      zen?      dent?
          tial #) Degree  (yyyy)                  Thesis Research Topic      Preceptor      Training Specialty  (Y/N)  (Y/N)   (Y/N)     (Y/N)
Page




       Refer to: Supplemental Instructions, page 10.
       1
        List Occ Med residents on this Table.




       Table 8
       [ ] Program                                                                                                                         Center Director:



       ERC Applicant Institution:
       Program Director:
       Discipline:
                                                                      Table 9
                                         NIOSH Positions Awarded Since Beginning of Current Project Period
                                                    Progress Report for Competing Applications

         Total # NIOSH         # Pre-Doc                                                Total # of   # Post-Doc                            Total # of
           Positions            Trainees                                                Months of     Trainees                             Months of
           Awarded1            Appointed              Pre-Doc degrees/level             Support2     Appointed    Post-Doc degrees/level   Support2
       Year 1: July 1, 200x to June 30, 200x



       Year 2: July 1, 200x to June 30, 200x
Page




       Year 3: July 1, 200x to June 30, 200x



       Year 4: July 1, 200x to June 30, 200x




       Refer to: Supplemental Instructions, page 12.
       1
         Full-time, full-year NIOSH awards since last competing renewal application.
       2
         Total for all months of support for all supported trainees in this category.




       Table 9
           [ ] Program                                                                                                                         Center Director:



       ERC Applicant Institution:
       Program Director:
       Discipline:
                                                                          Table 10
                                                Trainees Supported Since Beginning of Current Project Period1
                                                         Progress Report for Competing Applications

                                                                                              Year
                                    Year                                         Highest    Awarded    Source of
                                  Entered                                       Degree at   Previous    Support
                                  Program          Trainee's Previous           Program      Degree    for Each Name of Research
          Trainee Name2            (yyyy)              Institution                Entry     (mm/yy)      Year3      Mentor         Title of Research Project
       Year 1




       Year 2
Page




       Year 3



       Year 4



       Year 5




       Refer to: Supplemental Instructions, page 12.
       1
         List trainees supported since the last competing renewal application, by year.
       2
         Trainee counts include all students in the approved programs.
       3
         Use additional lines as needed for multiple sources of support.


           Table 10
       [ ] Program                                                                                                                   Center Director:



       ERC Applicant Institution:
       Program Director:
                                                                               Table 11
                                                                     Continuing Education Faculty

                                                                 Primary Affiliation1 [If Academic, include Department]       Role in Proposed CE
                     Faculty Name                             Discipline                               Institution/Employer         Program2
Page




       Refer to: Supplemental Instructions, page 10.
       1
         Industrial Hygiene, Occupational Health Nursing, Agricultural Safety and Health, etc.
       2
         Instructor, speaker, course director, etc.



       Table 11
       [ ] Program                                                                                                                                    Center Director:



        ERC Applicant Institution:
        Program Director:
                                                                         Table 12a
                                                           CE Course Offerings by Program Area
                                                    Previous Budget Period: July 1, 200x to June 30, 200x

                                                                              Program Area:

                                                                              # Trainees by Profession                           # Trainees by Employer

                                                 Length Total
            Course/Seminar       Program Total     of   Pers                           Private Fed State Local Foreign Acad
                 Title1            Area Trainees Course Days MD NURS HYG SAFETY OTHER Industry Gov Gov Gov Country emic Other
Page




        Subtotal [Program]       [e.g., IH]     0          0       0      0      0      0       0          0         0       0        0   0      0          0        0



        Refer to: Supplemental Instructions, page 10.
        1
         Group together by Program Area and provide sub-totals for each Program Area in Table 12b. Add or delete rows as necessary.




       Table 12a                                                                                                                                          [Program Area]
       [ ] Program                                                                                                                          Center Director:



       ERC Applicant Institution:
       Program Director:
                                                                         Table 12b
                                                     Summary of CE Course Offerings by Program Area
                                                    Previous Budget Period: July 1, 200x to June 30, 200x

                                                                              # Trainees by Profession               # Trainees by Employer

                                                Total # Total
            Course/Seminar     Program Total      of    Pers                                       Private Fed State Local Foreign Acad
                 Title1          Area Trainees Courses Days              MD NURS HYG SAFETY OTHER Industry Gov Gov Gov Country emic Other

       Subtotal IH                  IH

       Subtotal OHN                 OHN

       Subtotal OMR                 OMR

       Subtotal OS                  OS
Page




       Subtotal HST                 HST

       Subtotal Ag S&H          Ag S&H

       Subtotal Other               OT
       Category

       GRAND TOTALS (All                       0         0         0      0      0     0     0           0   0   0     0      0       0          0         0
       Program Areas)

       Refer to: Supplemental Instructions, page 10.
       1
        Group together by Program Area and provide sub-totals for each Program Area.




           Table 12b                                                                                                                      All Program Areas
       [ ] Program                                                                                                              Center Director:



       ERC Applicant Institution:
       Program Director:
                                                                   Table 12c
                                                 CE Course Offerings - Summary by Program Area
                                                    Since Beginning of Current Project Period

                                                                    # Trainees by Profession               # Trainees by Employer
                                                Number Total
                                     Total # of   of   Pers                                Private Fed State Local Foreign Acad
              Program Area           Trainees Courses Days     MD   NURS HYG SAFETY OTHER Industry Gov Gov Gov Country emic Other
       Industrial Hygiene (IH)

       Occupational Health Nursing
       (OHN)
       Occupational Medicine (OM)

       Occupational Safety (OS)
Page




       Hazardous Substance
       Training (HST)

       Agricultural Safety and
       Health (Ag S&H)

       Other OS&H, e.g. Tox, Epi,
       Ergo, Biostat (OT)

       TOTAL                            0         0      0     0      0      0      0          0   0   0      0     0       0       0       0




       Table 12c
       [ ] Program                                                                                                                              Center Director:



       ERC Applicant Institution:
       Program Director:
       Discipline:
                                                                               Table 13
                                                                      Minority Recruitment Data1
                                                               Since Beginning of Current Project Period

                              GROUP DATA                                                                      INDIVIDUAL DATA
                                                                           For those        Current Status
                                                                         who entered          (in training,
                         # of Minorities                                   program:         graduated, left
       # of Minorities       Offered         # of Minorities              Identify by        the program,                             Subsequent Career
          Applied          Admission       Entered Program               sequential #              etc.)      Sources of Support   Development/ Employment
       Year 1: July 1, 200x to June 30, 200x
Page




       Year 2: July 1, 200x to June 30, 200x



       Year 3: July 1, 200x to June 30, 200x



       Year 4: July 1, 200x to June 30, 200x




       Refer to: Supplemental Instructions, page 11.
       1
        First three columns are a group total; last four columns refer to individual trainees.




       Table 13
                                                                                                                      Center Director:



       ERC Applicant Institution:
       Center Director:
                                                                      Table 14
                                                               Human Subjects Grants
                                                           (For Section G of Training Plan)

             ERC Research                                                                       IRB Approval Date   Exemption
             Project/Grant #                         Project Title                       P.I.      (mm/dd/yy)       Designation
Page




       Refer to: Supplemental Instructions, page 1




       Table 14
                                                                                                          Center Director:



       ERC Applicant Institution:
       Center Director:
                                                                   Table 15
                                                            Animal Subjects Grants
                                                        (For Section H of Training Plan)

              ERC Research                                                                        IACUC Approval Date
              Project/Grant #                         Project Title                        P.I.       (mm/dd/yy)
Page




       Refer to: Supplemental Instructions, page 2.




       Table 15
                         Table 16 - ERC TRAINING GRANT KEY PERSONNEL AND OTHER SIGNIFICANT CONTRIBUTORS                                                                                              Jan. 2006

                           FTE SPREADSHEET FOR NEXT PROPOSED BUDGET PERIOD: July 1, 200x to June 30, 200x

       NAME                                Role on    Center Industrial   Occup.     Occup.    Occup.   Component    Agri-      Health      Occup. Injury     Pilot        NORA         HST   HSAT   CE/O   TOTAL
       (Faculty and Professional Staff)     Project   Admin.   Hygiene Health Nurs. Medicine   Safety   Programs    culture   Services RT   Prevent. RT     Project RT   Res. Support                        FTE


       1                                                                                                                                                                                                         0

       2                                                                                                                                                                                                         0

       3                                                                                                                                                                                                         0

       4                                                                                                                                                                                                         0

       5                                                                                                                                                                                                         0

       6                                                                                                                                                                                                         0

       7                                                                                                                                                                                                         0
Page




       8                                                                                                                                                                                                         0

       9                                                                                                                                                                                                         0

       10                                                                                                                                                                                                        0

       11                                                                                                                                                                                                        0

       12                                                                                                                                                                                                        0

       13                                                                                                                                                                                                        0

       14                                                                                                                                                                                                        0

       15

       16                                                                                                                                                                                                        0

       * For each individual, report the FTE devoted to the program that is specifically supported by NIOSH grant funding. Please identify key personnel via # and/or bold.


            GRANTEE INSTITUTION: ___________________________

            GRANT NUMBER: ____________________                                                                                                       DATE SUBMITTED: __________________

				
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