UNSOM Grant Application

Transcription

1 UNSOM Women's Fund WHF001 LEAVE BLANK FOR SADR USE ONLY. Activity: BS CS Number: University of Nevada School of Medicine UNSOM Grant Application Review Group Dean s Review (Month, Year) Do not exceed character length restrictions indicated. Date Received 1. TITLE OF PROJECT (Do not exceed 80 characters, including spaces and punctuation.) 3. PROGRAM DIRECTOR/PRINCIPAL INVESTIGATOR 3a. NAME (Last, First, Middle) 3b. DEGREE(S) 3c. POSITION TITLE 3d. MAILING ADDRESS (Street, city, state, zip code) 3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT 3f. MAJOR SUBDIVISION 3g. TELEPHONE AND FAX (Area code, number and extension) TEL: ADDRESS: FAX: 4. HUMAN SUBJECTS RESEARCH 4a. Research Exempt 4b. UNR IRB Application. and Status 4c. Includes a Clinical Trial 5. VERTEBRATE ANIMALS If, Exemption. 4d. Includes NIH-defined Phase III Clinical Trial 5a. Protocol. & Status (Active/Pending) 6. DATES OF PROPOSED PERIOD OF SUPPORT (month, day, year MM/DD/YY) 7. COSTS REQUESTED FOR INITIAL BUDGET PERIOD 8. COSTS REQUESTED FOR PROPOSED PERIOD OF SUPPORT From 7. Direct Costs ($) 8. Direct Costs ($) Through 9. APPLICANT MAJOR DEPARTMENT 10. COLLABORATING DEPARTMENT 12. DEPARTMENT ADMINISTRATOR TO BE NOTIFIED IF AWARD IS MADE 13. OFFICIAL SIGNING FOR UNSOM Jean T. Regan, CPA, MBA Title Title Senior Associate Dean, Finance University of Nevada School of Medicine Tel: FAX: Tel: (775) jregan@unr.edu FAX: (775) SIGNATURE OF OFFICIAL NAMED IN APPLICANT CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge, and accept the (In ink. Per signature not acceptable.) obligation to comply with UNSOM terms and conditions if a grant is awarded as a result of this application. SIGNATURE OF PI NAMED IN 3. Face Page DATE Form Page 1

2 PROJECT SUMMARY (See instructions): RELEVANCE TO WOMEN S HEALTH (include significance, innovation, expected outcomes, proposed timelines and plans for future funding). Page 2 WHF0002 Form Page 2

3 CENTER PERFORMANCE SITE(S) Project/Performance Site Primary Location Department : Clinic if Applicable: Street 1: Street 2: City: County: State: Zip/Postal Code: Additional Project/Performance Site Location (if applicable) Department : Clinic if Applicable: Street 1: Street 2: City: County: State: Zip/Postal Code: SENIOR/KEY PERSONNEL. Start with Program Director(s)/Principal Investigator(s). List all other senior/key personnel in alphabetical order, last name first. (key personnel are all those making significant intellectual contributions to the project whether paid or unpaid). Last First Department Role on Project DESCRIBE THE LEADERSHIP PLAN Page 3 Number the following pages consecutively throughout the application. Do not use suffixes such as 4a, 4b. WHF0003 Form Page 3

4 The name of the program director/principal investigator must be provided at the top of each printed page and each continuation page. UNSOM WOMEN S HEALTH PROPOSAL TABLE OF CONTENTS Page Numbers Face Page... 1 Description, Project/Performance Sites, Senior/Key Personnel, Other Significant Contributors Table of Contents... Detailed Budget for Initial Budget Period... Budget for Entire Proposed Period of Support... Budget Justification. Biographical Sketch Program Director/Principal Investigator (t to exceed two pages)... Other Biographical Sketches (t to exceed two pages each)... Existing Resources... Research Plan (Do NOT exceed 5 typed pages for Items1-3 below.) Introduction and Background * Specific Aims * Research/Problem Strategy Bibliography and References Cited/Progress Report Publication List (no page limit) Protection of Human Subjects (approval letter if applicable) Vertebrate Animals (approval letter if applicable) Letters of Support (e.g., consultants/services if applicable) Outcomes Sharing Plan... Appendix (Up to three publications from the PI/team applicable to the proposal may be included) An appendix is optional. Check if Appendix is Included * One page maximum for each for these sections; up to 6 pages total for items 1 through 3. Page 4 WHF 004

5 DETAILED BUDGET FOR INITIAL BUDGET PERIOD DIRECT COSTS ONLY FROM THROUGH List PERSONNEL (UNSOM only) Use Cal, Acad, or Summer to Enter # of 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 PD/PI SUBTOTALS CONSULTANT COSTS EQUIPMENT (Itemize) SUPPLIES (Itemize by category) TRAVEL INPATIENT CARE COSTS OUTPATIENT CARE COSTS OTHER EXPENSES (Itemize by category) TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD Form Page 5 $ WPF005 Form Page 5

6 BUDGET FOR ENTIRE PROPOSED PROJECT PERIOD DIRECT COSTS ONLY (Limit 2 years) BUDGET CATEGORY TOTALS INITIAL BUDGET PERIOD (from Form Page 5) 2nd ADDITIONAL YEAR OF SUPPORT REQUESTED PERSONNEL: Salary and fringe benefits. Applicant organization only. CONSULTANT COSTS EQUIPMENT SUPPLIES TRAVEL INPATIENT CARE COSTS OUTPATIENT CARE COSTS OTHER EXPENSES TOTAL DIRECT COSTS TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD $ JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed. ILOB (Rev. 01/15 ) Form Page 6 WHF006 Form Page 6

7 SAMPLE BIOGRAPHICAL SKETCH NOTE: Use the accompanying Word document "Biographical Sketch" for the PI and each participating faculty using the sections as described below. NAME POSITION TITLE 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 MM/YY FIELD OF STUDY (if applicable) A. Personal Statement Briefly describe why your experience and qualifications make you particularly well-suited for your role (e.g., PD/PI, mentor, participating faculty) in the proposal that is the subject of the application. Within this section you should assess your own scholarship and productivity and how that will benefit the proposed project. B. Positions and Honors List in chronological order previous positions held in the last ten years, concluding with the present position. List any honors. Include present membership on any federal or state government public advisory committees or commissions if applicable to the proposal. C. Selected Peer-reviewed Publications Applicants should limit the list of selected peer-reviewed publications or manuscripts in press to no more than 5. Do not include manuscripts submitted or in preparation. The individual should include only publications directly applicable to the proposed project. Particular attention should be made to assuring that only articles that are the result of peer-review be included in the publications list. Pamphlets, abstracts, posters and similar contributions that are not peer-reviewed are not to be included. If no publications state, ne. D. Project Support List both ongoing or completed research projects for the past five years (Federal or n-federally-supported) if they are pertinent to the proposal as funding or cofunding. Do not list funding history unless directly relevant to the proposed project. Briefly indicate the overall goals of the projects and responsibilities of the key person identified on the Biographical Sketch. For funded projects that are directly applicable to the current proposal, include number of person months and direct costs. If similar proposals are pending elsewhere, list them and their current status. Form Page 7 Biographical Sketch Format Page WHF007