Center for Healthy Aging Research
Doctoral Life Scholars Summer Research Program 2015
Application Form
Life Scholars must work with two faculty mentors from the Center for Healthy Aging Research.
Submission Instructions:
Include this application form and the following original (single-sided) documents as a complete proposal packet.
 Resume (including GPA and transcript)
 Letter of support from both faculty project advisors
(Attach documents to the back of the original application form)
Provide original and 3 copies (double-sided) of the complete proposal packet.
Mail or deliver complete proposal packet to: Holly Lenz, Center for Healthy Aging Research, 471 Waldo,
Oregon State University, Corvallis, OR 97331
Proposal packets must be received by 4:30 P.M. on the deadline date.
Incomplete proposal packets will not be considered for funding.
For program overview go to: http://health.oregonstate.edu/healthy-aging
1. Student Name:
First
Middle
Last
2. Major:
College:
Mailing Address:
Phone:
E-mail:
Expected Date of Graduation (m/m/yy):
Current GPA:
3. Project Title:
4. Project Facilitated through which department?
5. Describe any previous undergraduate research experience you have.
6. Faculty Project Advisor 1:
Faculty Project Advisor 2:
Department:
Phone:
None
Department:
E-mail:
Phone:
E-mail:
Name of Department Head:
Name of Department Head:
Name of College Dean:
Name of College Dean:
Center for Healthy Aging Life Scholars Application
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2/8/2016
LIFE SCHOLARS FUNDS REQUESTED
7. BUDGET
INSTRUCTIONS:

Refer To Guidelines for complete instruction on Use of Funds and Award Information

Itemize and list your budget items in detail (quantity, item, price and justification)

Round Figures to the Nearest Dollar
I. Student Wages (calculate at rate $
/hr x
hrs)
$
Add OPE Costs for undergraduate student ($2.43 per month)
$
Add Total monthly wages
$
x .005
II. Travel Expenses (justification)
$
Provide justification here
OSU travel guidelines can be reviewed at:
http://oregonstate.edu/fa/manuals/tra
III. Supplies, Expendables and Other Costs
(Supplies, Expendables, Lab items, copying etc.)
$
TOTAL BUDGET REQUEST:
$
Total Parts I, II, and III
Center for Healthy Aging Life Scholars Application
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2/8/2016
8. REGULATORY COMPLIANCE:
If your research project involves the use of human subjects, live vertebrate animals, DNA, ionizing radiation or
chemical carcinogens, you must be compliant and receive approval from the compliance committee prior to the start
of your research. If you are unsure, check both with your faculty advisor and the appropriate committee.
Check each box that applies to your research:
Does this proposal involve the use of human subjects?
If yes, approval from IRB must be received prior to start of project.
Yes
No
Yes
No
http://oregonstate.edu/research/osprc/rc/humansubjects.htm
Does this proposal involve the use of live vertebrate animals?
If yes, approval from IACUC must be received prior to start of project.
http://oregonstate.edu/research/osprc/rc/animal/use.html
Does this proposal involve the use of Recombinant DNA molecules?
Yes
No
If yes, approval from Environmental Health & Safety must be received prior to start of project.
http://oregonstate.edu/research/osprc/rc/biosafety.htm
Does this proposal involve sources of ionizing radiation?
Yes
No
If yes, approval from Radiation Safety Office must be received prior to start of project.
http://oregonstate.edu/research/osprc/rc/radiationsafety.htm
Does this proposal involve the use of chemical carcinogens or agents/ materials that are potentially pathogenic
to humans?
Yes
No
If yes, approval from Environmental Health & Safety must be received prior to start of project.
http://oregonstate.edu/research/osprc/rc/chemicalsafety.htm
9. SIGNATURES: (Provide all signatures)
a. I (the student) give Oregon State University permission to use my name, photograph, proposal, report, a summary
and/or excerpts of it, for the Center for Healthy Aging Research website, other OSU websites and/or other
publications for the sole purpose of sharing information about research and scholarship for students.
b. I (student and advisor) understand that participation in the LIFE Scholars program includes the preparation of a
scholarly report on my research, submitted in September, participation in a lab tour and a presentation on my research
at a colloquia or approved event.
Student
Date
Faculty Project Advisor 1
Date
Project Advisor’s Department Head
Date
Faculty Project Advisor 2
Date
Continue
Center for Healthy Aging Life Scholars Application
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2/8/2016
10. Project Description (Attach up to 2 pages, double-spaced, 12 pt. font): The purpose of this award is to promote
interdisciplinary, collaborative research among students and faculty. Briefly describe the research that is
proposed including methodologies and approaches. Summarize the scholarly and creative aspects of the project
and how this supports your educational objectives. What are the plans for publishing the research?
11. Synergy (Attach up to 2 pages, double-spaced, 12 pt. font): What aspects of your research enhance your
collaborative learning between you and your project advisors? What are the leveraging opportunities for funding
or further research? In other words, will the project lead to additional opportunities for either you or the advisor?
(New or additional funding for the work; professional/creative opportunities that would not have otherwise been
developed).
Center for Healthy Aging Life Scholars Application
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