RTRN Small Grants Program – Grant Application – 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
3i. E-MAIL ADDRESS:
3h. TELEPHONE AND FAX (Area code, number and extension)
TEL:
FAX:
3j. SEX:
MALE
3l. RACIAL
CATEGORY:
(optional)
AMERICAN INDIAN / ALASKA NATIVE
BLACK OR AFRICAN AMERICAN
WHITE / CAUCASIAN
4. HUMAN SUBJECTS RESEARCH
No
3k. ETHNIC CATEGORY: HISPANIC
(optional)
FEMALE
Yes
4b. Federal-Wide Assurance No.
If “Yes,” Exemption No.
Yes
4c. Clinical Trial
No
5. VERTEBRATE ANIMALS
ASIAN
NATIVE HAWAIIAN / OTHER PACIFIC ISLANDER
MORE THAN ONE RACIAL IDENTITY
4a. Research Exempt
No
No
4d. NIH-defined Phase III Clinical Trial
Yes
No
Yes
6. PROPOSED PERIOD OF SUPPORT: 07/01/2015
– 06/30/2016
7. ENTITY IDENTIFICATION NUMBER:
DUNS NO:
8. RCMI PI OR PD TO BE NOTIFIED, IF AWARD IS MADE
Name
Title
Address
Address
E-MAIL:
RTRN SGP Template for 2015-2016 Funding Cycle
CONGRESSIONAL DIST:
9. OFFICIAL FOR APPLICANT ORGANIZATION
Name
Title
FAX:
Yes
5a. Animal Welfare Assurance No.
TOTAL COSTS REQUESTED:
TEL:
NON HISPANIC
TEL:
E-MAIL:
Face Page
FAX:
Principal Investigator (Last, First, Middle):
10. PRIMARY COLLABORATOR OR MULTIPLE PRINCIPAL INVESTIGATOR (select one)
CLINICAL RESEARCHER
BASIC SCIENCE RESEARCHER
COMMUNITY RESEARCHER
10a. NAME (Last, first, middle)
10b. DEGREE(S)
10c. LISTED IN PROFILES
10d. ACADEMIC RANK (Professor, Associate Professor, Assistant Professor)
10g. MAILING ADDRESS (Street, city, state, zip code)
No
Yes
10e. INSTITUTION
10f. PRIMARY CLUSTER AFFILIATION
10h. TELEPHONE AND FAX (Area code, number and extension)
TEL:
10i. E-MAIL ADDRESS
FAX:
11. SECONDARY COLLABORATOR OR MULTIPLE PRINCIPAL INVESTIGATOR (select one)
CLINICAL RESEARCHER
BASIC SCIENCE RESEARCHER
COMMUNITY RESEARCHER
LAY COMMUNITY MEMBER
11a. NAME (Last, first, middle)
11b. DEGREE(S)
11c. LISTED IN PROFILES
11d. ACADEMIC RANK (Professor, Associate Professor, Assistant Professor)
11g. MAILING ADDRESS (Street, city, state, zip code)
No
Yes
11e. INSTITUTION
11f. PRIMARY CLUSTER AFFILIATION
11h. TELEPHONE AND FAX (Area code, number and extension)
TEL:
11i. E-MAIL ADDRESS
FAX:
IF APPLICANT IS AN ASSISTANT PROFESSOR, COMPLETE SECTIONS 12 AND 13
12. PRIMARY MENTOR (select one)
CLINICAL RESEARCHER
BASIC SCIENCE RESEARCHER
12a. NAME (Last, first, middle)
COMMUNITY RESEARCHER
12b. DEGREE(S)
12c. LISTED IN PROFILES
No
12d. ACADEMIC RANK (Professor, Associate Professor)
Yes
12g. MAILING ADDRESS (Street, city, state, zip code)
12e. INSTITUTION
12f. PRIMARY CLUSTER AFFILIATION
12h. TELEPHONE AND FAX (Area code, number and extension)
TEL:
12i. E-MAIL ADDRESS
FAX:
13. SECONDARY MENTOR (select one)
CLINICAL RESEARCHER
BASIC SCIENCE RESEARCHER
13a. NAME (Last, first, middle)
COMMUNITY RESEARCHER
13b. DEGREE(S)
LAY COMMUNITY MEMBER
13c. LISTED IN PROFILES
No
13d. ACADEMIC RANK (Professor, Associate Professor)
13g. MAILING ADDRESS (Street, city, state, zip code)
13e. INSTITUTION
13f. PRIMARY CLUSTER AFFILIATION
13h. TELEPHONE AND FAX (Area code, number and extension)
TEL:
FAX:
Yes
13i. E-MAIL ADDRESS
Page 2
Principal Investigator (Last, First, Middle):
PROJECT SUMMARY:
OBJECTIVE:
CENTRAL HYPOTHESIS:
SIGNIFICANCE:
INNOVATION:
APPROACH:
TRANSLATIONAL ASPECT OF RESEACH:
RELEVANCE TO HEALTH DISPARITIES:
Page
3
Principal Investigator (Last, First, Middle):
PROJECT/PERFORMANCE SITE(S) (if additional space is needed, use Project/Performance Site Format Page)
Project/Performance Site Primary Location
Organizational Name:
DUNS:
Street 1:
Street 2:
City:
County:
Province:
State:
Country:
Zip/Postal Code:
Project/Performance Site Congressional Districts:
Additional Project/Performance Site Location
Organizational Name:
DUNS:
Street 1:
Street 2:
City:
County:
Province:
State:
Country:
Zip/Postal Code:
Project/Performance Site Congressional Districts:
SPECIFY THE TYPE OF COLLABORATIVE ARRANGEMENT THIS APPLICATION REPRESENTS:
CLINICAL RESEARCHER AND CLINICAL RESEARCHER
CLINICAL RESEARCHER AND COMMUNITY RESEARCHER
CLINICAL RESEARCHER AND BASIC SCIENCE RESEARCHER
COMMUNITY RESEARCHER AND COMMUNITY RESEARCHER
COMMUNITY RESEARCHER AND CLINICAL RESEARCHER
COMMUNITY RESEARCHER AND BASIC SCIENTIST
BASIC SCIENCE RESEARCHER AND CLINICAL RESEARCHER
BASIC SCIENCE RESEARCHER AND COMMUNITY RESEARCHER
SENIOR/KEY PERSONNEL. Start with Program Director(s)/Principal Investigator(s). List all other senior/key personnel in alphabetical order, last name
first.
Role on Project
Name
Institution
e-mail
OTHER SIGNIFICANT CONTRIBUTORS
Role on Project
Name
Institution
e-mail
Principal Investigator
Multiple Principal Investigator
Multiple Principal Investigator
Primary Collaborator
Secondary Collaborator
Primary Mentor
Secondary Mentor
Human Embryonic Stem Cells
No
Yes
If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list:
http://stemcells.nih.gov/research/registry/eligibilityCriteria.asp. Use continuation pages as needed.
If a specific line cannot be referenced at this time, include a statement that one from the Registry will be used.
Cell Line
Page
4
Principal Investigator (Last, First, Middle):
RTRN SMALL GRANTS PROGRAM
TABLE OF CONTENTS
Page Numbers
Face Page ..................................................................................................................................................
Description, Project/Performance Sites, Senior/Key Personnel, Other Significant Contributors,
and Human Embryonic Stem Cells .........................................................................................................
Table of Contents .....................................................................................................................................
Detailed Budget for Initial Budget Period ..............................................................................................
Budget Justification .................................................................................................................................
Biographical Sketch – Principal Investigator (Not to exceed four pages) ...............................................
Other Biographical Sketches – Multiple Principal Investigator(s) or Collaborator(s) and/or Mentor(s)
(Not to exceed four pages each) ................................................................................................................
Other Support – Principal Investigator and Key Personnel ......................................................................
Research Plan ...........................................................................................................................................
1. Specific Aims (Not to exceed one page) .............................................................................................
2. Research Strategy (Not to exceed four pages) ..................................................................................
Significance .........................................................................................................................................
Innovation ............................................................................................................................................
Approach .............................................................................................................................................
3. Literature Cited (Not to exceed one page) ...........................................................................................
4. Protection of Human Subjects (if applicable) (no page limit) ...............................................................
5. Inclusion of Women and Minorities (if applicable) ...............................................................................
6. Inclusion of Children (if applicable) ......................................................................................................
7. Vertebrate Animals (if applicable) (no page limit) ................................................................................
8. Select Agent Research (if applicable) (no page limit) ..........................................................................
Appendix (None allowed)
1
2-4
5
6
7
Page 5
Principal Investigator (Last, First, Middle):
DETAILED BUDGET FOR BUDGET PERIOD
DIRECT COSTS ONLY
FROM
THROUGH
List PERSONNEL (Applicant organization only)
Use Cal, Acad, or Summer to Enter Months Devoted to Project
Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits
NAME
ROLE ON
PROJECT
Cal.
Mnths
Acad.
Mnths
Summer INST.BASE
Mnths
SALARY
SALARY
REQUESTED
FRINGE
BENEFITS
TOTAL
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
INPATIENT CARE COSTS
OUTPATIENT CARE COSTS
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
CONSORTIUM/CONTRACTUAL COSTS
DIRECT COSTS
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)
CONSORTIUM/CONTRACTUAL COSTS
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD
$
FACILITIES AND ADMINISTRATIVE COSTS - 50%
$
Page 6
Principal Investigator (Last, First, Middle):
BUDGET JUSTIFICATION FOR PROJECT PERIOD
Itemization and Budget Justification (Continue on another page if necessary)
Page 7
Principal Investigator (Last, First, Middle):
BIOGRAPHICAL SKETCH
Provide the following information for the Senior/key personnel and other significant contributors.
Follow this format for each person. DO NOT EXCEED FOUR PAGES.
NAME
ACADEMIC RANK
eRA COMMONS USER NAME (credential, e.g., agency login)
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and
residency training if applicable.)
DEGREE
INSTITUTION AND LOCATION
YEAR
FIELD OF STUDY
(if applicable)
A. Personal Statement
B. Positions and Honors
C. Selected Peer-Reviewed Publications
D. Research Support
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
BIOGRAPHICAL SKETCH
Provide the following information for the Senior/key personnel and other significant contributors.
Follow this format for each person. DO NOT EXCEED FOUR PAGES.
NAME
POSITION TITLE
eRA COMMONS USER NAME (credential, e.g., agency login)
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and
residency training if applicable.)
DEGREE
INSTITUTION AND LOCATION
YEAR
FIELD OF STUDY
(if applicable)
A. Personal Statement
B. Positions and Honors
C. Selected Peer-Reviewed Publications
D. Research Support
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
OTHER SUPPORT
Page
Principal Investigator (Last, First, Middle):
SPECIFIC AIMS (ONE-PAGE LIMIT)
Page
Principal Investigator (Last, First, Middle):
RESEARCH STRATEGY (FOUR-PAGE LIMIT)
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
LITERATURE CITED (ONE-PAGE LIMIT)
HUMAN SUBJECTS RESEARCH (If applicable)
VERTEBRATE ANIMALS (If applicable)
Page
Principal Investigator (Last, First, Middle):
Page
Principal Investigator (Last, First, Middle):
SUPPLEMENTAL MATERIALS TO BE UPLOADED with application
1. Letter(s) of Support from Multiple Principal Investigator(s), Collaborator(s) and /or Mentor(s)
2. LETTER OF SUPPORT FROM RCMI PI/PD OF APPLICANT INSTITUTION
3. LETTER(S) OF SUPPORT FROM RCMI PI/PD OF COLLABORATOR INSTITUTION(S), IF DUAL- OR
MULTI-SITE CLINICAL TRIAL IS BEING PROPOSED
4. COST ESTIMATE LETTER from Director of RTRN Data Coordinating Center
5. Evidence of IRB or IACUC Application or Approval (if applicable)
6. Targeted/Planned Enrollment Table (if applicable)
Page