PILOT PROJECT RESEARCH TRAINING PROGRAM
FUNDING APPLICATION
Fiscal year 2015-2016 Submit to Salvatore Cali per application instructions.
Submission deadline is 5:00 PM CST Tuesday, April 7, 2015
Follow application instructions provided at: http://www.uic.edu/sph/glakes/funding.html
( ) Application instructions have been read and followed.
( ) Electronic copy of application and full proposal attached.
NORA Sector (http://www.cdc.gov/niosh/nora/sector.html) and/or Priority Area(s):
___________________________________________________________________
Key words describing proposal:
PROJECT TITLE:
PRINCIPAL INVESTIGATOR:
Name (print)
_______________________
UIN or Organization ID #
Organization name
_____
Department name
Address
E-mail Address
Mail Code
Title/Rank
Phone
Appointed to this Rank (Mo./Yr.)
BUSINESS MANAGER:
Name (print)
E-mail Address
Mail Code
Phone
Location(s) of Research
COLLABORATORS (Names and Departments)
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_____
CHECK LIST SPECIAL CLEARANCES
Does this research involve Human Subjects?
Yes/ No
If "Yes", indicate if IRB application is pending and what type of application is expected or completed.
Circle or highlight one:
Pending: Yes/ No
Exemption: Yes/ No
Full IRB: Yes/ No
Expedited Review: Yes/ No
Other: _________________________
For applications shown above:

Assurance of compliance/ protocol #: _______________________

Date of first protocol submission: ________________________
Does this research involve Vertebrate Animals?
Yes/ No
If "Yes" IACUC approval date or if pending:___________________________
Animal welfare assurance #:________________________________
RESEARCH TO BE CONDUCTED (Check all that apply):
( ) Hospitals or clinics will be used……………………. Hospital/Clinic Approval
( ) Radiation or radioisotopes will be used…………… Permit Number
( ) Recombination DNA is involved……… Protocol No.
( ) Hospitals or clinics will be used…………………Hospital/Clinic Approval
( ) FDA/IND involved………………………………Number
( ) Radiation or radioisotopes will be used………Permit Number
( ) Research Resources Center equipment to be used………RRC approval
( ) Clinical Research Center to be used……………………… CRC approval
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EQUIPMENT REQUESTS:
Maximum equipment costs funded in whole or part by this award is $2,000; see equipment budget
guidelines in the application instructions.
SOURCE
AMOUNT
STATEMENT FROM PRINCIPAL INVESTIGATOR: I confirm that I have read the PPRT Grants
Policy Statement and will comply with any applicable Special Requirements and my written
research plan in the conduct of this research.
Name and Institution:
Date: ________________________
STATEMENT FROM DEPARTMENT/UNIT HEAD
All necessary space and supplies not requested in this application have been made available in the
department.
I confirm that the Principal Investigator is affiliated with my department as a:
____________________________________________________________
Department/Unit Head Signature
Date
Print Department/Unit Head Name
STATEMENT FROM RESEARCH MENTOR: (signature may be faxed if mentor is at a different
institution from applicant)
I confirm that I will advise the principal investigator in the scientific aspects of the conduct of
this research.
Name/Institution:
Mentor Signature
Date
Statement of Mentorship Support: Applicants must also identify and complete arrangements for a
research mentor who will provide guidance for the research. A signed agreement to mentor from a
senior investigator is required (see application). Further information on the role of a research mentor
is available at:
http://grants1.nih.gov/grants/guide/pa-files/PAR-04-105.html under the Special Requirements
section.
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Include a brief paragraph describing the role of the research mentor in this research project:
Other Support: Please include a statement regarding any actual or potential budgetary,
commitment, or scientific overlap of support. See the POLICY REGARDING OTHER SUPPORT
section of the Application Instructions for explanation:
Research Plan:
Abstract of Research Plan: State the project goal and objectives. Describe concisely the research
design and methods for achieving these objectives as well as the potential for improving safety and
health in the work environment (maximum 200 words).
Research Proposal: Attach the full proposal narrative (maximum 10 pages for the narrative, items
1-6). See the application instructions for organization of proposal and more detail about page limits.
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Currently Resources Available to Applicant:
Office:
Office Equipment:
Computer:
Laboratory:
Clinic:
Animal:
Environmental Sampling Equipment:
Other:
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