Grant Number: S06 GM _________(provide only if a competing renewal or supplement):
Institution:___________________________________________________________
1. Descriptive Title: (56 characters or less, including spaces)
________________________________________________________________________
2.Investigator(s): Last Name, First, M.I., Degree, Department
________________________________________________________________________
Type of Project:
Research Project _______ Pilot Research Project __________
New project : _______ Revised Application: _____ Competing renewal :______
If revision, Previous Submission Date: ___________
If completing renewal, Duration of prior support: _____ Years.
Level of support: $_______ avg./per year excluding equipment.
Number of FTE researchers: ______ per year
Is progress report included? Yes____ No____
If previously supported by another NIH Institute or other federal agency:
Grant(s) number(s): ________________, Period of support: _____________.
Level of support: $__________________________ avg. per year.
Number of research workers engaged on the project per year______________.
______________________________________________________________________
4. Protection against Research Risks:
A. Will human subjects be involved? Yes:____ No:_____
If “yes” is Research Exempt? Yes:____ No:______ If “yes” Exemption Number:
B. Will vertebrate animals be used? Yes: ____ No:______
If “yes, list the species_____________ and estimate the number to be used per year.
C. Are there potential hazards (including biohazards) to laboratory workers (carcinogens, pathogens, ionizing radiation, etc.) involved in the proposed research?
Yes:_____ No: ______
If yes, identify these below and address safety considerations in the text:
i.
ii.
iii.
iv.
v.
Signature (PI) _______________________