SAMPLE. PROGRAM ELIGIBILITY INFORMATION: (Responses to selected fields displayed below. For some grant programs this section may be blank.

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1 Grant Application Date Submitted: Proposal Type: If renewal, current grant: Resubmission? 1st or 2nd: TITLE OF PROJECT (s exceeding 81 characters, including spaces and punctuation, will be truncated.) Comm Code: APPLICANT NAME HIGHEST DEGREE(S) POSITION TITLE: ACADEMIC RANK: DIVISION: APPLICANT S CURRENT INSTITUTION MAILING ADDRESS (Street, city, state, postal code, country) DEPARTMENT: ADDRESS: Tel: Fax: PROGRAM ELIGIBILITY INFORMATION: (Responses to selected fields displayed below. For some grant programs this section may be blank.) DATES OF PROPOSED PROJECT (MM/DD/YYYY) From Through SIGNING OFFICIAL FOR PROPOSED BUDGET Tel: Fax: Tel: Fax: EIN ADDRESS DUNS HUMAN SUBJECTS No Yes VERTEBRATE ANIMALS No Yes Human Subjects Assurance No. IRB Status: IRB Date: Animal welfare assurance no. IACUC Status: IACUC Date: ASSURANCE OF THOSE SIGNING THIS APPLICATION: I certify that the statements in this Application that pertain to me and my are true, complete, and accurate to the best of my knowledge, and that I have provided all information required by this Application. I am aware that false, fictitious, or fraudulent statements or claims may result in criminal, civil, or administrative penalties. I agree that I will (and the Signing Official further represents that the institution will) comply with all Grant Policies of the Society, including reporting requirements, to the extent applicable. I understand that a failure to comply with such Policies, or the the terms of the Application, or any additional terms associated with a Grant, may result in the Society suspending or cancelling Grant funding, to be decided by the Society at its sole discretion. The Applicant certifies, and the Signing Official certifies that the has verified, that the Applicant is legally eligible to work in the United States of America for the period of the award. SIGNATURE OF APPLICANT DATE SIGNATURE OF DEPARTMENT HEAD DATE. SIGNATURE OF SIGNGING OFFICIAL DATE

2 Applicant: Application Contacts Tel: Fax: Tel: Fax: Tel: Fax: Tel: Fax: Tel: Fax: Tel: Fax: Tel: Fax: Tel: Fax:

3 GENERAL AUDIENCE SUMMARY APPLICANT NAME DATE SUBMITTED TITLE OF PROJECT (s exceeding 81 characters, including spaces and punctuation, will be truncated.) This General Audience Summary will become public information; therefore, do not include proprietary/confidential information.

4 Principal Investigator: [Click here and type last name, first name] 1.1 TABLE OF CONTENTS Cover Pages (Signature Page, Contact Page, General Audience Summary) Table of Contents Reply To Previous Review (Resubmitted and Renewal Applications) Previous Critiques (Resubmitted and Renewal Applications) Information Residency Program Information Biographical Sketch of Principal Investigator Biographical Sketches of Key Faculty Program Goals And Description Budget and Justification of Budget Required Letters Appendix: ACGME accreditation letter Copies of resident final reports Copies of resident schedules

5 Principal Investigator: [Click here and type last name, first name] 2.1 REPLY TO PREVIOUS REVIEW (FOR RESUBMISSIONS ONLY)

6 Principal Investigator: [Click here and type last name, first name] 3.1 INSTITUTION INFORMATION

7 Principal Investigator: [Click here and type last name, first name] 4.1 RESIDENCY PROGRAM INFORMATION 1. Provide the following information about the residency program's most recent accreditation by the Accreditation Council for Graduate Medical Education. Include in the appendix a copy of the letter of accreditation. If the program was cited by the ACGME, any issues/concerns raised must be addressed in item 4 below and a copy of the progress report attached. Date of accreditation: Effective period: Accreditation Status Full: Provisional: Probation: 2. For which years of residency training in preventive medicine is the program approved by ACGME? Indicate by providing number of approved resident positions. PGY1: PGY2: PGY3: PGY4: PGY5: Provide the number of residents in each year, i.e., how many approved positions are filled: PGY1: PGY2: PGY3: PGY4: PGY5: 3. The residency program (check all that apply in first column): Accepts residents with only PGY1 training. Accepts only residents with other board certification. Is a combined program (e.g., with internal medicine, family medicine, etc.). 4. Describe the residency program; beginning with relevant historical background such as the length of the program s accreditation, any statement of mission or training emphasis, the career paths of former residents, etc. If there have been major changes since the previous PTACP submission in the context of the residency in which this training program resides, such as a transition in program leadership, change in affiliation agreements, etc., please describe.

8 Principal Investigator: [Click here and type last name, first name] 4.2 TABLE OF PTACP RESIDENCY PROGRAM GRADUATES Grant Period (1/1/ - 6/30/ ) Resident Date Began/Date Graduated Date of ABPM Certification Current (or last known) Position, and Location Describe cancer prevention and control activities, if not obvious by position title.

9 Principal Investigator: [Click here and type last name, first name] 4.3 TABLE OF ALL RESIDENCY PROGRAM GRADUATES Resident Date Began/Date Graduated Date of ABPM Certification Current (or last known) Position, and Location Document any cancer relevance, if not obvious by position title.

10 Principal Investigator: [Click here and type last name, first name] 5.1 BIOGRAPHICAL SKETCH Provide the following information for the Principal Investigator and Key Faculty Follow this format for each person. DO NOT EXCEED TWO PAGES. NAME POSITION TITLE EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.) INSTITUTION AND LOCATION DEGREE (if applicable) YEAR(s) FIELD OF STUDY A. Certifications B. Current Activities and Previous Positions C. Professional Society Memberships and Service

11 Principal Investigator: [Click here and type last name, first name] 5.2 D. Academic/Professional Honor Societies, Consultantships, Appointed or Elected E. Representative Publications (identify with an asterisk any publications on cancer prevention and control)

12 Principal Investigator: [Click here and type last name, first name] 7.1 PROGRAM GOALS AND DESCRIPTION

13 Principal Investigator: [Click here and type last name, first name] 8.1 BUDGET Trainee Expenses Resident Stipends (salary and fringe benefits) Tuition and Fees Trainee Travel Other (describe) Year 1 Year 2 Year 3 Year 4 Year 5 (6 months) Non-trainee Expenses Personnel [Itemize all positions: include names of personnel, percent effort, and compensation (salary & fringe benefits)] Staff Travel Other (describe) Category Total Subcontracts (Categorize on continuation page) Category Total Permanent Equipment (Itemize) Category Total Supplies (Group into major categories) Category Total Miscellaneous (List specific amounts for each item) Category Total Direct Costs Total No indirect costs allowed. See Policies. Annual Total Total Amount Requested

14 Principal Investigator: [Click here and type last name, first name] 8.2 JUSTIFICATION OF BUDGET

SAMPLE. PROGRAM ELIGIBILITY INFORMATION: (Responses to selected fields displayed below. For some grant programs this section may be blank.

SAMPLE. PROGRAM ELIGIBILITY INFORMATION: (Responses to selected fields displayed below. For some grant programs this section may be blank. Grant Application Date Submitted: Proposal Type: If renewal, current grant: Resubmission? 1st or 2nd: TITLE OF PROJECT (s exceeding 81 characters, including spaces and punctuation, will be truncated.)