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International Research Questionnaire
Instructions: Please provide responses to the following questions. When completed, return to the Compliance
Officer and the Vice Chancellors for Research and Business and Finance
Name of Project:
Name of UNMC
Investigator(s):
Name of UNMC
Collaborator(s):
General Project Information
1.
What country(ies) outside the United States are involved
in this project?
1a.
What institutions or businesses are involved?
2.
2a.
3.
Will you be doing this research as UNMC faculty member
or will you be doing it as an outside consultant (outside
employment)?
If you are doing it as a UNMC faculty member, will UNMC
serve as the prime, a consultant, or a subcontractor?
What is the funding source for this project? What will it
fund?
4.
What is the nature of the proposed project (Scope of
Work—brief description)? (attach separate sheets, as
necessary)
4a.
Is this project related to or could it be perceived to be in
competition with other research/project currently
conducted at UNMC?
[ ] Yes
5.
The project will include which of the following (check all
that apply)?
☐ Research
☐ Instruction
☐ Public service
☐ Business relationship
6.
Please discuss the role(s) the you or other UNMC faculty
or staff have .
6a.
Are there any agreements anticipated to cover this
relationship (material transfer or Memorandum of
Understanding)?
Human Subjects
[ ] No If yes, explain:
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7.
7.a.
8.
9.
9.a.
9.b.
Will human subject research be conducted as part of this
research ?(If yes, complete 7.a; If no, move to question 8)
Will the human subject research be conducted in the US
or another country?
Will any protected health information (PHI) be gathered?
Will human biological samples be collected? (If yes,
complete 9.a. through 9.e; If no, move to question 10)
What type of specimens (e.g., blood, DNA, plant isolates,
bacterial or fungal isolates)?
Will stem cells be collected or used? If so, what type?
List the country(ies) from which the human biological
samples will be collected
9.d. To what location will the human biological samples be
sent?
9.e. Will the biological samples contain infectious agents or
isolates?
10.
Is any IRB exempt human subject research planned (e.g.,
epidemiology or human subjects data without identifiers)?
Animal Use
11.
Will animal research be included, whether conducted in
this US or another country? (If yes, complete 11.a; If no,
move to question 12)
11a. Will any living animals or specimens from animals be
transported to or from the country(ies)?
Materials and Equipment
12.
Will any item be transported that could be considered
dangerous during transport (e.g., dry ice, oxygen,
flammables, radionuclides)
13.
Will any equipment, material or supplies be purchased or
transported to or from the country identified? (If yes,
complete 13.a, 13.b, and 13.c; If no, move to 14)
13.a List the equipment, material software, or supplies (other
$?) to be transferred or purchased. If applicable, include
the Export Control Classification Number (ECCN) for
each. Please list.
13.b Specify the sending and receiving countries.
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☐ No
☐ Maybe/not
final
☐ Not
sure
☐ Yes ☐ No
☐ Maybe/not
final
☐ Not
sure
☐ Maybe/not
final
☐ Maybe/not
final
☐ Not
sure
☐ Not
sure
☐
Yes
☐ U.S.
☐ Other: ___________________________
☐ Yes
☐ No ☐ Maybe/not ☐ Not
final
sure
☐ Yes
☐ No ☐ Maybe/not ☐ Not
final
sure
9.c.
13.c. Which of the following best represents this equipment
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
☐ Maybe/not
final
☐ Not
sure
☐ Yes
☐ No
☐ Maybe/not
final
☐ Not
sure
☐ Yes
☐ No
☐ Maybe/not
final
☐ Not
sure
☐ Yes
☐ No
☐ Maybe/not
final
☐ Not
sure
☐ Shipped from USA
☐ Shipped from non-USA country
☐ UNMC equipment temporary sited in
country
☐ Purchased in USA
☐ Purchased in country
☐ Purchase outside of USA and shipped to
country
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Personnel
14.
☐
Yes
☐ No
☐
Maybe/not
final
☐
Not
sure
☐
Yes
☐ No
☐
Maybe/not
final
☐
Not
sure
Will any construction be completed within the country
(ies) specified above? (If yes, complete 15.a; If no,
move to 16)
What specifically will be constructed?
Will a local bank account or business partner be
needed for this partnership?
☐
Yes
☐ No
☐
Maybe/not
final
☐
Not
sure
☐
Yes
☐ No
17.
Does this project require special security status or
secure communication? (If yes, complete 17.a; If no,
move to 18)
☐
Yes
☐ No
☐
Maybe/not
final
☐
Maybe/not
final
☐
Not
sure
☐
Not
sure
17.a.
Please describe security requirements.
18.
Will non-UNMC students, staff, or collaborators be
allowed/provided access to UNMC computer
systems?
☐
Yes
☐ No
☐
Maybe/not
final
☐
Not
sure
Will non-UNMC students, staff or collaborators travel
to visit UNMC as part of this proposal?
☐
Yes
☐ No
☐
Maybe/not
final
☐
Not
sure
Please check any of the following who may travel
outside of the U.S.
☐ You
☐ Other UNMC faculty or staff
☐ UNMC students
14a.
14b.
Logistics
15.
15.a
16.
Travel
19.
20.
Will you or other UNMC employees work overseas?
What amount of time will you work overseas? How will
effort reporting be handled if you work on other
grants?
Will any visiting scholars or students come to UNMC
for this project? Describe scope and provide names
when available?
Conflict of Interest
21.
Do you or any participating faculty or staff have any
potential conflict of interest with the research? COI
Smart disclosure is required. Depending on nature of
engagement, Outside Employment approval may
need to be sought.
22.
Will you receive any direct or indirect remuneration
for participating in this research? If yes, describe in
detail.
23.
What human, facility, equipment, reagent etc.
resources for the research will be provided by the
foreign institution?
Intellectual Property (IP)
23.
Do you anticipate that any new inventions or IP will be
generated from this work?
☐
Yes
☐
No
☐
Yes
☐ No
24.
Will any third party materials or IP be used in this
project?
☐
Yes
☐ No
25.
Is an established University of Nebraska invention
patent or patent application involved in the project?
☐
Yes
☐ No
☐
☐ Not
Maybe/not sure
final
☐
Maybe/not
final
☐
Maybe/not
final
☐
Maybe/not
final
☐
Not
sure
☐
Not
sure
☐
Not
sure
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26.
Acknowledge
27.
Will any unpublished information need to be
transferred as part of this collaboration?
☐
Yes
☐ No
☐
Maybe/not
final
Do you acknowledge that you are aware of the state
and federal laws and Board of Regents and UNMC
policies listed in Policy # 8014 and agree to remain in
compliance with same during this research
engagement?
☐
Yes
☐ No
☐
Maybe/not
final
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☐
Not
sure
☐
Not
sure