Project Title
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Principal Investigator Name
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(First Last)
Campus/Region
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Charlotte Reynolda Campus Winston-Salem
Principal Investigator Department
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Principal Investigator Rank
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Professor Associate Professor Assistant Professor Instructor
Principal Investigator Email
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Co-Principal Investigator Name
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(First Last)
Campus/Region
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Charlotte Reynolda Campus Winston-Salem
Co-Principal Investigator Department
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Co-Principal Investigator Rank
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Professor Associate Professor Assistant Professor Instructor
Co-Principal Investigator Email
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How does the Principal Investigator self-identify their race? Check one or more.
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If other, please list:
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Does the Principal Investigator identify as Hispanic or Latinx?
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Yes No Do not wish to provide
How does the Principal Investigator self-identify their gender?
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Male Female Non-binary Prefer to self-describe Do not wish to provide
If prefer to self-describe, please list:
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Does the Principal Investigator have a disability?
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No Yes Do not wish to provide
If yes, please select one or more of the following:
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If other, please list:
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How does the Co-Principal Investigator self-identify their race? Check one or more.
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If other, please list:
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Does the Co-Principal Investigator identify as Hispanic or Latinx?
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Yes No Do not wish to provide
How does the Co-Principal Investigator self-identify their gender?
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Male Female Non-binary Prefer to self-describe Do not wish to provide
If prefer to self-describe, please list:
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Does the Principal Investigator have a disability?
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No Yes Do not wish to provide
If yes, please select one or more of the following:
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If other, please list:
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Number of Project Key Personnel (do not include PI or Co-PI)
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Key Personnel 1 Name
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Key Personnel 1 Department
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Key Personnel 1 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 1: Do they spend 30% or more effort in direct patient care?
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Yes No
Key Personnel 2 Name
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Key Personnel 2 Department
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Key Personnel 2 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 2: Do they spend 30% or more effort in direct patient care?
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Yes No
Key Personnel 3 Name
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Key Personnel 3 Department
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Key Personnel 3 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 3: Do they spend 30% or more effort in direct patient care?
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Yes No
Key Personnel 4 Name
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Key Personnel 4 Department
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Key Personnel 4 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 4: Do they spend 30% or more effort in direct patient care?
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Yes No
Key Personnel 5 Name
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Key Personnel 5 Department
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Key Personnel 5 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 5: Do they spend 30% or more effort in direct patient care?
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Yes No
Key Personnel 6 Name
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Key Personnel 6 Department
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Key Personnel 6 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 6: Do they spend 30% or more effort in direct patient care?
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Yes No
Key Personnel 7 Name
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Key Personnel 7 Department
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Key Personnel 7 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 7: Do they spend 30% or more effort in direct patient care?
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Yes No
Key Personnel 8 Name
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Key Personnel 8 Department
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Key Personnel 8 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 8: Do they spend 30% or more effort in direct patient care?
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Yes No
Key Personnel 9 Name
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Key Personnel 9 Department
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Key Personnel 9 Rank
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Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
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Key Personnel 9: Do they spend 30% or more effort in direct patient care?
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Yes No
Abstract (300 words max)
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Research Strategy (6 pages max) - Specific Aims - Research Plan
Significance Innovation Approach Study Team - Study Milestones and anticipated outcomes with timeline
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References (no page limit)
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Does the proposed work involve human subjects?
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Yes
No
Unsure
Are the participants prospectively assigned to an intervention?
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Yes
No
Is the study designed to evaluate the effect of the intervention on the participants?
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Yes
No
Is the effect that will be evaluated a health-related biomedical or behavioral outcome?
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Yes
No
IRB Approval
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Already have IRB approval for the proposed work Plan on submitting an amendment to an existing IRB approved project if funded Plan on initiating a new IRB application if funded IRB approval is not needed for the proposed work
IRB Number
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Please explain why IRB approval is not needed for project involving human subjects.
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Will this project be classified as a clinical trial?
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Yes No Unsure
Please provide more information on why you are 'unsure' about the proposed work being classified as a clinical trial.
Type of Clinical Trial
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Phase 0 drug clinical trial Phase I drug clinical trial Phase II drug clinical trial Phase III drug clinical trial Phase IV drug clinical trial Device clinical trial Non-FDA regulated clinical trial
Addressing Human Subjects
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Inclusion of Individuals Across the Lifespan
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Inclusion Plans for Women, Minorities, and Children (if not applicable, upload a document stating this)
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Data and Safety Monitoring Plan (DSMP) and Board (DSMB) (if not applicable, upload a document stating this)
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Does the proposed work involve live vertebrates?
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Yes No Unsure
IACUC Approval
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Already have IACUC approval for the proposed work Plan on submitting an amendment to an existing IACUC approved project if funded Plan on initiating a new IACUC application if funded IACUC approval is not needed for the proposed work
Please explain why IACUC approval is not needed for project involving live vertebrates.
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IACUC Number
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Budget Justification (1 page max)
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Biosketch for ______
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Letter(s) of Support, if needed
Other Supporting Documentation, if needed
Submit
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