RTRN Small Grants Program – Letter of Intent – 2015
1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation)
2. TRANSLATIONAL RESEARCH LEVEL (select one): T1
T2
T3
T4
T1- Translation to Humans T2- Translation to Patients T3- Translation to Practice T4- Translation to Population Health
3. PRINCIPAL INVESTIGATOR (select one)
CLINICAL RESEARCHER
BASIC SCIENCE RESEARCHER
COMMUNITY RESEARCHER
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3c. LISTED IN PROFILES
No
3d. ACADEMIC RANK (Professor, Associate Professor, Assistant Professor)
Yes
3g. MAILING ADDRESS (Street, city, state, zip code)
3e. INSTITUTION
3f. PRIMARY RTRN CLUSTER AFFILIATION
3h. TELEPHONE AND FAX (Area code, number and extension)
TEL:
3i. E-MAIL ADDRESS:
FAX:
4. PRIMARY COLLABORATOR OR MULTIPLE PRINCIPAL INVESTIGATOR (select one)
CLINICAL RESEARCHER
BASIC SCIENCE RESEARCHER
COMMUNITY RESEARCHER
4a. NAME (Last, first, middle)
4b. DEGREE(S)
4c. LISTED IN PROFILES
No
4d. ACADEMIC RANK (Professor, Associate Professor, Assistant Professor)
Yes
4g. MAILING ADDRESS (Street, city, state, zip code)
4e. INSTITUTION
4f. PRIMARY CLUSTER AFFILIATION
4h. TELEPHONE AND FAX (Area code, number and extension)
TEL:
4i. E-MAIL ADDRESS
FAX:
5. PRIMARY MENTOR (IF APPLICANT IS ASSISTANT PROFESSOR) (select one)
CLINICAL RESEARCHER
BASIC SCIENCE RESEARCHER
COMMUNITY RESEARCHER
5a. NAME (Last, first, middle)
5b. DEGREE(S)
5c. LISTED IN PROFILES
5d. ACADEMIC RANK (Professor, Associate Professor)
5g. MAILING ADDRESS (Street, city, state, zip code)
No
Yes
5e. INSTITUTION
5f. PRIMARY CLUSTER AFFILIATION
5h. TELEPHONE AND FAX (Area code, number and extension)
TEL:
5i. E-MAIL ADDRESS
FAX:
6. PROJECT SUMMARY (50 Word Limit) (OBJECTIVE, TRANSLATIONAL ASPECT OF RESEACH and RELEVANCE TO HEALTH DISPARITIES)
Three Key Words:
Please submit the LOI template electronically to [email protected], with a copy to the DCC ([email protected]).
RTRN SGP Letter of Intent Template for 2015-2016 Funding Cycle
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PHS 398, fp4 (Rev. 11/07), Detailed Budget for Initial Budget Period