Protocol Submission Checklist (Continued)

Community Health: Assessment and Improvement
Measures Program (CHAMP)
Checklist
Scientific Review Panel of CCaTS

This form must be completed and returned with the Community Health: Assessment and Improvement Measures Program application to ensure a complete submission. Your package MUST follow the order of the submission checklist. Incomplete applications will be sent back without review.

Please bundle all application documents into one PDF file using this completed checklist as a face page. Scan the Research Budget template then merge it with your complete PDF application. Submit via email to .

REQUIREMENTS FOR ALL APPLICATIONS
Project title:
PI: / Dept/Division & appointment category:
CI: / Dept./Division & appointment category:
CI: / Dept./Division & appointment category:
CI: / Dept./Division & appointment category:
CI: / Dept./Division & appointment category:
External collaborator(s): / Organization:
Biosketch (NIH template) – include co-investigators (include list of current and past funding)
Template available at
Download form pages for the new biosketch
Protocol (use template)

Letter of endorsement from Department/Division chair
Name of chair: ______
The following is an example letter that must be signed by your Department/Division chair:

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Protocol Submission Checklist (Continued)

Letter of support if work will be done in a laboratory by an investigator who is not already listed on this application Not applicable
Letter of support if work is done with a community engaged stakeholder. Not applicable
. IACUC/IRB submission date: If approved, IACUC/IRB#:
Note: IRB/IACUC approval is not required to meet the application deadline; however, should funding be approved, the study cannot be initiated without IRB/IACUC final review and approval.
Budget funding proposal # ______
Complete the budget template below and email it to Sue Rubow by August 12, 2016. A budget will be created and sent back to you for review. When finalized, attach it to your application. A budget must be created before you submit your application.

Total direct costs: $
Total indirect costs:$
Total cost: $

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Protocol Submission Checklist (Continued)

Budget justification (template)

Have you or any of the listed investigators applied for any intramural or extramural funding for this
specific protocol?
Yes (If yes, list program(s) ______) No
Please list 5 keywords that describe your research protocol
Co-investigator(s) have committed to participate on this project

Please address memos and cover letters to Dr. Carlos Mantilla, Chair of the Community Health Assessment and Improvement Measures Program Panel Committee.

Questions regarding the use of this form should be directed to Susan Rubowat 5-7089,

1Rev. 01/2016