Office for Human Research Studies
DANA-FARBER / HARVARD CANCER CENTER
OHRS Use Only:
DFCI Protocol No.:
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NP:
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Research Funding Form
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Please use this form to indicate how a new research study will be funded or submit along with the Amendment Form to report a
change in funding to previously IRB approved research.
Please contact your institutional Grants and Contracts office at as soon as possible if there are any delays in funding from the
sponsor(s).
Studies will be put on administrative hold if the sponsor advises either the study team or the contracts office of a
delay or the contracts office is having difficulty negotiating with the sponsors.
This form must be submitted via OHRS Submit.
Please contact the OHRS at (617) 632-3029 or by email ohrs@dfci.harvard.edu with any questions.
Part A – STUDY INFORMATION
1. Full Protocol Title:
2. Protocol version/date:
3. Please check one:
Initial submission
Amended submission
4. DFCI Protocol Number (if known):
Part B – FUNDING INFORMATION
1. FUNDING INFORMATION TYPE [Please select all that apply.]
a) Government/Federal Funding (such as NCI/NIH) – Please submit a copy of the entire grant for
IRB review.
1) Funding Sponsor Name:
2) Grant No. (if known, otherwise inform OHRS when grant no. is assigned)
3) Grant PI Name:
4) Title of Grant Proposal:
5) If this is not being submitted at this time, explain why:
6) Please Briefly Describe Funding Provided/Requested:
7) If this is supported by the Department of Defense (DoD):
a. Will the protocol require review by the USAMRMC’s Human Subject Research Review
Board (HSRRB) or Human Research Protocol Office (HRPO)?
No
Yes If yes,
then please complete and submit the Department of Defense Supplement Form.
8) Subcontract from outside DFHCC site (if applicable):
No
Yes, please specify outside site name:
9) Funding Status (Please select one).
Submission pending. Submitted deadline / Expected Submission Date:
Submitted but not funded. Submission date:
Submitted and funded. Award start date:
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Award end date:
Version 10.02.15
Other. Please describe:
b) Foundation Funding (such as the American Cancer Society)
1) Funding Sponsor Name:
2) Sponsor Contact Name, Telephone and Address:
3) Title of Grant Proposal:
4) Sponsor Protocol Number (if applicable):
5) Please Describe Funding Provided:
6) Subcontract from outside DFHCC site (if applicable):
No
Yes, please specify outside site name:
7) Funding Status (Select One):
Submission pending. Submitted deadline / Expected Submission Date:
Submitted but not funded. Submission date:
Submitted and funded. Award start date:
Award end date:
Other. Please describe:
c) Industry Funding (such as Johnson & Johnson or Astra Zeneca)
1)
Funding Sponsor Name:
2) Sponsor Contact Name, Telephone and Address:
3) Sponsor Protocol Number (if applicable):
4) Please Describe Funding Provided:
5) Subcontract from outside DFHCC site (if applicable):
No
Yes, please specify outside site name:
6) Funding Status (Select One):
Contracts Pending.
Contracts Executed.
Other. Please describe:
d) Internal Funding (funded by DF/HCC)
1) Funding Contact Name, Telephone and Address:
2) Please Describe Funding Provided:
3) Subcontract from a DFHCC site to any other sites (if applicable):
No
Yes, please specify site names:
4) Funding Status - Please describe:
e) Cooperative Group Funding (Indicate one of the following groups only: Alliance for Clinical Trials
in Oncology, COG, ECOG-ACRIN Cancer Research Group, NCIC Clinical Trials Group, NRG Oncology
Group, SWOG):
Research Funding Form
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1) Sponsor Protocol Number (if applicable):
2) Funding Contact Name, Telephone and Address:
3) Title of Grant Proposal:
4) Please Describe Funding Provided:
5) Funding Status - Please describe:
f) Consortium Funding:
1) Sponsor Protocol Number (if applicable):
2) Funding Contact Name, Telephone and Address:
3) Title of Grant Proposal:
4) Please Describe Funding Provided:
5) Funding Status - Please describe:
g) Applying for Protocol Specific Research Support Funds. These funds provide support for DF/HCC
investigator-initiated early phase clinical research that is unfunded or underfunded. If this box is selected,
OHRS will forward the submission to Dr. Jeffrey Clark, Chair of the Scientific Resource and Prioritization
Committee. Please contact Dr. Clark (Massachusetts General Hospital) at (617) 643-3415 with any questions.
h) No Funding
i)
Other, please describe:
Part C – Electronic Signatures
Form completed by:
Name:
Date:
Phone:
E-mail:
The Overall Principal Investigator assures that the information provided in this submission is complete and accurate, and
that it is consistent with proposal(s) submitted to external funding agencies. The Overall Principal Investigator assures
that modifications to the originally approved project will not take place without prior review and approval by the
Institutional Review Board, and that all activities will be performed in accordance with state and federal regulations and
Dana-Farber/Harvard Cancer Center Policies and Procedures.
Name of Overall Principal Investigator:
Research Funding Form
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