Community-Engaged Cooperative Agreement - Rapid Response RFA
Project Title:
* must provide value
Principal Investigator (name, rank, department):
* must provide value
Number of Project Key Personnel
* must provide value
Key Personnel 1 Name
* must provide value
Key Personnel 1 Department
* must provide value
Key Personnel 1 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Key Personnel 2 Name
* must provide value
Key Personnel 2 Department
* must provide value
Key Personnel 2 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Key Personnel 3 Name
* must provide value
Key Personnel 3 Department
* must provide value
Key Personnel 3 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Key Personnel 4 Name
* must provide value
Key Personnel 4 Department
* must provide value
Key Personnel 4 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Key Personnel 5 Name
* must provide value
Key Personnel 5 Department
* must provide value
Key Personnel 5 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Key Personnel 6 Name
* must provide value
Key Personnel 6 Department
* must provide value
Key Personnel 6 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Key Personnel 7 Name
* must provide value
Key Personnel 7 Department
* must provide value
Key Personnel 7 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Key Personnel 8 Name
* must provide value
Key Personnel 8 Department
* must provide value
Key Personnel 8 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Key Personnel 9 Name
* must provide value
Key Personnel 9 Department
* must provide value
Key Personnel 9 Rank
* must provide value
Professor Associate Professor Assistant Professor Instructor Other
If 'Other', please specify.
* must provide value
Abstract (30 lines max)
* must provide value
Specific Aims (1 page max)
* must provide value
Research Plan (6 pages max)
Specific Aims (1 page max)
Background and significance, translational importance, experimental design and methods, dissemination and implementation plan (4 pages max)
Study Milestones and anticipated outcomes with timeline (1 page max)
Contribution and summary of qualification of each contributing investigator (1 page max)
* must provide value
References (no page limit)
* must provide value
Does the proposed work involve human subjects?
* must provide value
Yes No Unsure
IRB Approval
* must provide value
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
* must provide value
Please explain why IRB approval is not needed for project involving human subjects.
* must provide value
Will this project be classified as a clinical trial?
* must provide value
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
* must provide value
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 (1 page max)
* must provide value
Inclusion Plans for Women, Minorities, and Children (if not applicable, upload a document stating this)
* must provide value
Data and Safety Monitoring Plan (DSMP) and Board (DSMB) (if not applicable, upload a document stating this)
* must provide value
Does the proposed work involve live vertebrates?
* must provide value
Yes No Unsure
IACUC Approval
* must provide value
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.
* must provide value
IACUC Number
* must provide value
Budget Justification (1 page max)
* must provide value
Biosketch for [pi_name]
* must provide value
Biosketch for ______
* must provide value
Biosketch for ______
* must provide value
Biosketch for ______
* must provide value
Biosketch for ______
* must provide value
Biosketch for ______
* must provide value
Biosketch for ______
* must provide value
Biosketch for ______
* must provide value
Biosketch for ______
* must provide value
Biosketch for ______
* must provide value
Letter(s) of Support, if needed
Other Supporting Documentation, if needed
Submit
Save & Return Later
