Principal Investigator:
_____________________________________________________________________________________
Pediatric Mini-Grant Application
Project Title:
Date of Application:
Principal Investigator:
Degree:
Position:
Address:
Phone Number:
Fax:
Email:
Department:
Division:
Applicant Category:
 Faculty
 Resident or Fellow in Pediatrics,  Medicine-Pediatrics,  Other
(list Department and Division) _________________
My project Mentor is _____________________
Anticipated date of training completion: _________________
 Mentor letter of support attached
 Medical student at UNMC
Date of matriculation: _________________
Anticipated date of graduation: __________
My project Mentor is ___________________
Note: Project must be completed by the time of graduation
 Mentor letter of support attached
IRB Approval:
IACUC Approval:
Endorsing Chair of
Applicant’s Division:
Total Funds Requested:
(maximum $5,000)
Dates of Proposed Project
Period:
Site of Project:
Principal Investigator
Signature:
Protocol #:
Approval Date: __________ or Pending?_____
Project is exempt from IRB approval? _________
Protocol #:
Approval Date: __________ or Pending?_____
Project is exempt from IACUC approval? _________
Name:
Note: Electronic submission implies approval of Division Chair
Signature: Electronic submission implies signature of applicant.
1
Principal Investigator:
_____________________________________________________________________________________
Project Type (check one)
 Case report
 Case series
 Retrospective chart review
 Prospective exploratory study
 Prospective interventional investigation (drug, device, procedural change, etc.)
 Laboratory-based project
 Other (please describe) _____________________________________________
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Principal Investigator:
_____________________________________________________________________________________
Project Abstract *
Project Title:
Abstract:
Objective:
Methods:
Relevance to pediatrics:

Please do not exceed this 1 page length.
3
Principal Investigator:
_____________________________________________________________________________________
Project Budget
List cost estimates for research supplies, contract services, clinical tests, patient travel, laboratory technician costs,
statistical analysis, research software, small equipment, publication costs, etc. Costs that are not allowed include
administrative or secretarial support, clinical consultant fees, and investigator salary and travel. Student salary
stipend for research support is allowed.
Project Title:
Detailed Project Budget
From:
Through:
Personnel:
Dollar amount requested:
Name
Title/Position
% Effort
Principal
Investigator
Salary
Not allowed
Fringe
Benefits
Not allowed
Totals
0
Subtotals:
Supplies (please itemize):
Other:
Total Request:
$
4
Principal Investigator:
_____________________________________________________________________________________
Budget Justification
Provide justification for major budgetary items in each of the project budget categories (Personnel, Supplies,
Other).
Personnel:
Supplies:
Other:
Are matching funds available to support this research? If so, include source and amount:
5
Principal Investigator:
_____________________________________________________________________________________
Biographical Sketch
Investigator:
Project Title:
Name
Position / Title
Education/Training (begin with baccalaureate or other initial professional education, such as nursing, and include
postdoctoral training).
Institution and Location
Degree
Year(s)
Field of Study
Positions: List in chronological order, concluding with present position.
Relevant, recent publications (in chronological order; limit to 15 maximum):
6
Principal Investigator:
_____________________________________________________________________________________
Research Plan
Do not exceed 3 pages, exclusive of references.
1. Hypothesis
2. Specific Aims
3. Background/Preliminary Data
4. Experimental Design/Methods
5. Statistical Analysis
6. Potential Pitfalls/Alternatives
7. Significance to Pediatrics
8. References
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