Clinical and Translational Research Funding Program
BARNES-JEWISH HOSPITAL FOUNDATION AND
WASHINGTON UNIVERSITY INSTITUTE OF CLINICAL AND TRANSLATIONAL SCIENCES
Title of Project (no more than 81 characters):
Type of Research (check one): T1 T2 T3 T4 / Dates of Project Period:
06/01/2015 – 05/31/2016
Research Focus (check all that may apply): Cancer Child Health / Total Funds Requested:
$ Direct Costs
Principal Investigator (PI)
Name: (Last, First, Middle) / Degree(s):
Title: / Mailing Address:
Applicant Organization:
Department: / Division: / E-mail Address: / Phone Number:
Grant Administrator
Contact Name: / Grant Administrator
Phone Number: / Grant Administrator E-mail Address:
Human Subjects: Yes No
Approval Date: Pending
IRB Approval #:
Exempt: Yes No
Federal Wide Assurance No.
Clinical Trial? Yes No -- If yes, Phase #: / Vertebrate Animals: Yes No
Approval Date: Pending
IACUC Approval #:
Animal Welfare Assurance No.
As PI of this project:
I certify that the information submitted within this application is true, complete and accurate to the best of my knowledge. If this proposal is funded, I agree to accept responsibility for the scientific conduct of the project, to conduct the project in accordance with the policies of the sponsoring organization, and to provide progress reports in a timely manner.
I will comply with the Resource Sharing Plan. / Official Signing for Applicant Organization:
(See Instructions)
Name:
Title:
Address:
Tel:
Fax:
E-mail:
Principal Investigator Signature: / Date: / Official Signature: / Date:

BJHF/ICTS 06/2014 Face Page Form Page 1

Principal Investigator (Last, First, Middle):
ABSTRACT (150 words or less)
SHORT PROJECT DESCRIPTION (450 characters maximum, including spaces)
Please use layman’s terms. This will be used on the website, if funded.
ESTABLISHED INVESTIGATORS (note if N/A)
Describe how this project will lead to a new direction in your research or is different from your previous work

BJHF/ICTS 06/2014 Abstract Page Form Page 2

Principal Investigator (Last, First, Middle):
RESEARCH THEME (Check all that apply: see complete descriptions in the Program Overview)
Improving the Quality of Patient Care
Enhancing Patient Safety
Improving Patient Outcomes / Improving Transfer to Practice
Translating Genetic/Genomic Findings
Development/Evaluation of Therapeutics
Describe how your proposed project is relevant to one or more of the BJHF/ICTS Research Themes:
IMPACT
Considering the significance, approach, innovation and the environment as described in your proposal, describe the potential impact for this project to exert a sustained influence on the research field(s) involved. Be specific about the steps necessary for this project to reach human application using language easily understood by reviewers outside of your area of specialty.

BJHF/ICTS 06/2014 Themes & Impact Page Form Page 3

Principal Investigator (Last, First, Middle):

Identify the ICTS Core(s) you consulted with in preparation of this application and/or that you anticipate using if this project receives funding.

P = Preparation, I = Implementation (check all that apply)

P I
Research Design & Biostatistics Group
Dissemination & Implementation Research Core
Center for Administrative Data Research
Center for Clinical Research Ethics
Recruitment Enhancement Core
Regulatory Support Center
Center for Biomedical Informatics
Genomic Medicine Program
Human & Mouse Linked Evaluation of Tumors
Proteomics & Mass Spectrometry / P I
Clinical Research Unit (CARS)
Pediatric Clinical Research Unit (CARS)
Clinical Trials Unit (CARS)
Lifestyle Intervention Research Core (CARS)
Human Imaging Unit
Center for Community-Engaged Research
Translational Pathology & Tissue Banking
Translational Cardiovascular Biobank &
Repository
Other, non-ICTS associated cores:
Estimate the percentage (%) of activity of the proposed project that will be conducted in a laboratory setting and a non-laboratory/other setting (total must equal 100%)
- Laboratory Setting
- Non-Laboratory/Other Setting
PROJECT PERFORMANCE SITES(s) and SHORT DESCRIPTION OF RESOURCES:

BJHF/ICTS 06/2014 Resources Page Form Page 4

Principal Investigator (Last, First, Middle):

KEY PERSONNEL:

List the individuals who contribute to the scientific development or execution of the project in a substantive, measurable way, whether or not salaries are requested. These individuals will have effort included on the budget or will be a paid consultant.

Start with Principal Investigator. List all other key personnel in alphabetical order, last name first.

Name Organization / Department Role on Project

OTHER SIGNIFICANT CONTRIBUTORS:

List the individuals who have committed to contribute to the scientific development or execution of the project, but are not committing any specified measurable effort to the project. Unpaid consultants/collaborators should be included if they meet this definition.

Name Organization / Department Role on Project

BJHF/ICTS 06/2014 Personnel Page Form Page 5

Principal Investigator (Last, First, Middle):

REVIEWER SUMMARY BUDGET FOR BUDGET PERIOD

DIRECT COSTS ONLY

/ FROM / THROUGH
06/01/2015 / 05/31/2016
PERSONNEL / % / DOLLAR AMOUNT REQUESTED (omit cents)
NAME / ROLE ON
PROJECT / EFFORT
ON
PROJ. / INST.
BASE
SALARY / SALARY
REQUESTED / FRINGE
BENEFITS / TOTAL
Principal
Investigator
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTS / INPATIENT
OUTPATIENT
CONSORTIUM COSTS
OTHER EXPENSES (Itemize by category)
TOTAL DIRECT COSTS / $

BJHF/ICTS 06/2014 Reviewer Summary Budget Page Form Page 6A