Applicant Information:
Principal Investigator:
Name:
Institution:
Address:
Phone:
Email:
Are you eligible at your home institution to apply for an NIH grant as a principal investigator?
Yes No
Co-Investigator 1:
Name:
Institution:
Address:
Phone:
Email:
Co-Investigator 2:
Name:
Institution:
Address:
Phone:
Email:
Co-Investigator 3:
Name:
Institution:
Address:
Phone:
Email:
Original Study Information:
Original project title:
Original specific aims:Provide the specific aims for the original study in one or two paragraphs. You may copy the project description from the NIH RePORTER entry.
Original study design: Provide a description of the original study design.
Health outcomes:Describe the specific children’s health outcomes of the original study.
Environmental exposure measures: Describe environmental exposuresassessments, if any, that have already been completed. This can include for example, previous analysis of biospecimens for chemical or stress biomarkers; metabolomics and/or gene expression profiles; collection of air, soil or water samples; and/or administration ofquestionnaires relating to stress, dietary or environmental exposures of interest.
Summary of findings from original study: Provide a brief summary of the key findings from your original funded study.
Human subjects’ approval: Record the institution providing IRB approval and the IRB approval number for your original study.
Approving institution:
Approval number:
Key publications: Provide the DOIs for up to fivepublications that describe the original study.
Proposed CHEAR P&F Project:
Project title:
Specific aims:
Significance: Describe how the requested CHEAR analyses will provide data to support a future grant application and how this pilot study and the future grant will enhance the findings from your original study.
Requested Analyses Table:Please complete the table below to provide information aboutyourcollected biospecimens and requested analyses.Additional information about analyses of exposure or biologic response can be found on the CHEAR website under Working with CHEAR > Lab Analysis Services.If you have any questions about the types or costs of analyses provided by CHEAR, or about the suitability of your samples for your requested analyses,please contact the CHEAR Coordinating Center at before you submit your application.
CHEAR Pilot and Feasibility Program Application Page 1
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Requested Analyses Table
Requested analysis / Participant type / Age or development stage at collection / Sample matrix / Number of samples / Totalvolume/quantity per participant
(with units) / Collection method / Storage temp (with units) / Number of freeze-thaws
Pregnant mothersMothersFetusesInfantsChildrenTeensFathers / BC = Buffy CoatBR = Breast MilkBU = Buccal CellCB = Cord BloodCSF = Cerebrospinal FluidD = DNADBS = Dried Blood SpotsH = HairME = MeconiumN = NailsP = PlasmaPL = PlacentaR = RNARBC = Red Blood CellsS = SerumSL = SalivaST = StoolSU = SputumT = TeethTI = TissueU = UrineWBC = White Blood Cells
Pregnant mothersMothersFetusesInfantsChildrenTeensFathers / BC = Buffy CoatBR = Breast MilkBU = Buccal CellCB = Cord BloodCSF = Cerebrospinal FluidD = DNADBS = Dried Blood SpotsH = HairME = MeconiumN = NailsP = PlasmaPL = PlacentaR = RNARBC = Red Blood CellsS = SerumSL = SalivaST = StoolSU = SputumT = TeethTI = TissueU = UrineWBC = White Blood Cells
Pregnant mothersMothersFetusesInfantsChildrenTeensFathers / BC = Buffy CoatBR = Breast MilkBU = Buccal CellCB = Cord BloodCSF = Cerebrospinal FluidD = DNADBS = Dried Blood SpotsH = HairME = MeconiumN = NailsP = PlasmaPL = PlacentaR = RNARBC = Red Blood CellsS = SerumSL = SalivaST = StoolSU = SputumT = TeethTI = TissueU = UrineWBC = White Blood Cells
Pregnant mothersMothersFetusesInfantsChildrenTeensFathers / BC = Buffy CoatBR = Breast MilkBU = Buccal CellCB = Cord BloodCSF = Cerebrospinal FluidD = DNADBS = Dried Blood SpotsH = HairME = MeconiumN = NailsP = PlasmaPL = PlacentaR = RNARBC = Red Blood CellsS = SerumSL = SalivaST = StoolSU = SputumT = TeethTI = TissueU = UrineWBC = White Blood Cells
Additional comments about samples or analyses: Provide any additional comments about your available samples or the proposed analyses, if applicable.
CHEAR Pilot and Feasibility Program Application Page 1
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Study design: Describe the proposed study design.
Statement of analysis objectives:
Study subject numbers:Indicate the total number of study subjects for whom biological samples will be provided.
Human subjects’ approval: Include approval numbers for human subjects’ research or indicate status of approval process.
CHEAR Publication Policy: Have you reviewed and are you willing to agree to theCHEAR Publication Policy?
Yes No
Anticipated timeline for P&F project:
Anticipated source of funding for future project:
Anticipated timeline for future project:
Please complete this application and submit it, along with biosketches for the Principal Investigator and all Co-Investigators, to .
CHEAR Pilot and Feasibility Program Application Page 1
V.1
Effective date: 11/21/2017