PI Name: ___________________________
Application for an Individual Allocation from
American Cancer Society
Institutional Research Grant #IRG-92-024
(1 of 2 pages)
PROJECT TITLE:
INVESTIGATOR (Name, Degree, Title, Department, and School or College):
AMOUNT REQUESTED: _____________ TERM: from ________ to ________
TYPE OF APPLICATION: _____________ RESEARCH AWARD
_____________
SPECIAL INTEREST AWARD
_____________ RENEWAL APPLICATION
MENTOR(S) (Name, Degree, Title, Department, and School or College):
BUDGET PROPOSED:
A. Personnel
B. Permanent Equipment
C. Supplies
D. Miscellaneous
TOTAL ________
UNM ACS IRG Application (revised 12/2010, updated 10/2012)
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PI Name: ___________________________
Application for an Individual Allocation from
American Cancer Society
Institutional Research Grant #IRG-92-024
(2 of 2 pages)
BUDGET JUSTIFICATION:
OTHER RESEARCH SUPPORT:
UNM ACS IRG Application (revised 12/2010, updated 10/2012)
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PI Name: ___________________________
Application for an Individual Allocation from
American Cancer Society
Institutional Research Grant #IRG-92-024
RESEARCH PLAN:
(use continuation pages – RESEARCH PLAN can be up to 7 pages)
UNM ACS IRG Application (revised 12/2010, updated 10/2012)
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PI Name: ___________________________
Application for an Individual Allocation from
American Cancer Society
Institutional Research Grant #IRG-92-024
ENVIRONMENT AND FUTURE PLANS
Space and Facilities Available for the Project:
Time Available for Research:
Association with a Mentor:
Interactions with the Research Community:
Plan for Transition to External Funding:
UNM ACS IRG Application (revised 12/2010, updated 10/2012)
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PI Name: ___________________________
Application for an Individual Allocation from
American Cancer Society
Institutional Research Grant #IRG-92-024
Biographical Information
(2 pages maximum)
Last name, first name (with degrees)
*Citizenship status: _____ U.S. citizen or non-citizen national
_____ Permanent resident alien
Major research interest:
Education
Degree/year conferred
Institution/location
Field of Study
Training
Title
Mentor
Institution/location
Dates
Appointments
Title
Institution/location
Dates
* Only citizens and permanent residents may receive ACS IRG grants
Publications
Use Continuation page
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PI Name: ___________________________
Cancer Relevance Information
The general public and, specifically, our donors need to be aware and informed about the Society's research
programs so they may continue supporting these programs. The American Cancer Society emphasizes that it is
the investigator's responsibility to explain the relevance, importance, and potential impact of the proposed
research in terms which can be easily understood by neighbors, the voting public, children in schools, and by
individuals donating money for cancer research. Donors frequently have an interest in funding particular types
of cancer research and priority areas and organ sites must be selected for these summaries to be presented to
donors for special funding opportunities. In Sections I, II, III, and IV, please provide the requested information
by following the instructions provided.
Name of Applicant
I.
Title of Project
Priority Areas: Next to all terms that apply to your proposal, indicate the percentage of effort devoted to
each (use decimal format, i.e., .30 will signify 30%).
CATEGORY (Note: Error if total not 100%)
BIOLOGY
1.1-Cancer Related Biology
1.2-Resources and Infrastructure Related to Biology
ETIOLOGY
2.1-Exogenous Factors
2.2-Endogenous Factors
2.3-Interactions of Genes and/or Genetic
Polymorphisms with Exogenous and/or Endogenous
Factors
2.4-Resources and Infrastructure Related to Etiology
PREVENTION
3.1-Interventions to Prevent Cancer: Personal
Behaviors that Affect Cancer Risk
3.2-Nutritional Science in Cancer Prevention
3.3-Chemoprevention
3.4-Vaccines
3.5-Complementary and Alternative Prevention
Approaches
3.6-Resources and Infrastructure Related to
Prevention
EARLY DETECTION, DIAGNOSIS, AND
PROGNOSIS
4.1-Technology Development and/or Marker Discovery
4.2-Technology and/or Marker Evaluation with Respect
to Fundamental Parameters of Method
4.3-Technology and/or Marker Testing in a Clinical
Setting
4.4-Resources and Infrastructure Related to Detection,
Diagnosis, or Prognosis
TREATMENT
5.1-Localized Therapies-Discovery and Development
%
Effort
%
Effort
CATEGORY (Note: Error if total not 100%)
TREATMENT (cont’d)
5.2-Localized Therapies-Clinical Applications
5.3-Systemic Therapies-Discovery and Development
5.4-Systemic Therapies-Clinical Applications
5.5-Combinations of Localized and Systemic Therapies
5.6–Complementary and Alternative Treatment Approaches
5.7-Resources and Infrastructure Related to Treatment
CANCER CONTROL, SURVIVORSHIP, AND OUTCOMES
6.1-Survivorship Issues (Post-Treatment Concerns)
6.2-Patient Care (Diagnosis Through Treatment)
Supportive
6.3-Surveillance
Including
6.4-Behavior Related to Cancer Control
6.5-Cost Analyses and Health Care Delivery
6.6-Education and Communication
6.7-End-of-Life Care
6.8-Ethics and Confidentiality in Cancer Research
6.9-Complementary and Alternative Approaches for Supportive
Care of Patients and Survivors
6.10-Resources and Infrastructure Related to Cancer Control,
Survivorship, and Outcomes Research
SCIENTIFIC MODEL SYSTEMS
7.1-Development of Model Systems
7.2-Characterization of Model Systems
7.3-Resources and Infrastructure Related to Scientific Model
Systems
TOTAL EFFORT (Must total 100%)
UNM ACS IRG Application (revised 12/2010, updated 10/2012)
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1.00
PI Name: ___________________________
II.
Organ Sites: Next to all terms that apply to your proposal, indicate the percentage of effort devoted to
each. Use decimal format, i.e., .30 = 30%. (Note: Total must be 0% or 100%)
SITE
Adrenal
Blood
Brain
Cartilage
Cervix, uterine
Endometrium
Esophagus
Gastrointestinal tract
Head and neck
Kaposi’s sarcoma
Leukemia
Lung
Melanoma
Myeloma, multiple
Non-Hodgkin’s Lymphoma
Pancreas
Pharynx
Platelets
Respiratory system
Salivary glands
Soft tissue sarcoma
Testis
Trachea, bronchus
Vagina
III.
%
EFFORT
SITE
Anus
Bone
Breast
Colon, rectum
Connective tissue
Embryonic tissue, cells
Eye
Genital system, female
Heart
Kidney, renal cell
Leukocytes
Lymph nodes
Mesothelioma
Nervous system
Nose, nasal passages
Parathyroid
Pituitary
Prostate
Retinoblastoma
Skin, non-melanoma
Spleen
Thymus
Urinary system
Wilm’s tumor
%
EFFORT
SITE
Bladder
Bone marrow
Buccal cavity
Central nervous system
Ear
Erythrocytes
Gall bladder
Genital system, male
Hodgkin’s lymphoma
Larynx
Liver
Lymphatic system
Muscle
Neuroblastoma
Ovary
Penis
Placental tissue, cells
Reticuloendothelial system
Rhabdomyosarcoma
Small intestine
Stomach
Thyroid
Uterus
TOTAL
General Audience Summary (describe within the space allotted below, in non-technical language, how
your project relates to cancer in general or specifically to one or more of the above categories.)
UNM ACS IRG Application (revised 12/2010, updated 10/2012)
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%
EFFORT
PI Name: ___________________________
American Cancer Society Institutional Research Grant - Research Promotion Form
(Optional)
If your application for an American Cancer Society grant is funded, the American Cancer Society
Southwest Division would like to announce your success and to invite you to work with the
Society to promote research to the media and the general public. Please indicate your response
to the following questions:
1. If you are conducting research, are you willing to discuss your project(s) with the media?
____
yes
____
no
2. Would you assist your local ACS Division or Unit by speaking at Society-sponsored events, for
example, fundraising, professional or public education, Board or committee meetings?
____
yes
____
no
3. Would you assist your local ACS Division or Unit by serving as an expert in your research or
professional field and/or as a member of a speaker’s bureau?
____
yes
____
no
4. Would you assist your local ACS Division or Unit in fundraising events - for example,
organizing a team to participate in the Relay for Life?
yes
no
5. If there are other ways you would like to assist the Society, please list here:
6. Contact Information
Name:
Phone:
Fax:
E-mail:
UNM ACS IRG Application (revised 12/2010, updated 10/2012)
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PI Name: ___________________________
The University of New Mexico
ACS IRG Checklist
1.
Does the project involve human subjects?
Yes ____
No ____
If yes, has it been approved by the HRRC? (HRRC Approval # required)
If it has not been approved, please explain.
_________________________________________
2.
Does this project involve laboratory animals?
Yes ____
No ____
If yes, has it been approved by the IACUC? (Animal protocol # required)
If it has not been approved, please explain.
_________________________________________
Director, ARF ___________________________________
3.
Have you included a letter from your Department Chair or Division Chief endorsing
your project, choice of mentor and plan for transition to independence? The letter
should confirm your release time for research.
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