Department of Veterans Affairs (Use Only Administrative Code 02)

FUNDING SOURCE CODES

Department of Veterans Affairs (Use only Administrative Code 02)

Research Advisory Group (CC 103)

Merit Review (CC 103)

Special Research Initiatives (CC 106)

Career Development (CC 108)

[9009]

[9022]

[9023]

[9024]

Other Designated Research (CC 109)

Rehabilitation R&D (Prog 822)

Agent Orange & Related Herbicides

Health Services R&D (Prog 824)

[9025]

[9050]

[9092]

Cooperative Studies (Prog 825)

Clinical Science R&D

Musculoskeletal Research

[9002]

[9003]

[9006]

[9008]

National Institutes of Health and Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA)

National Cancer Institute

National Eye Institute

National Heart, Lung & Blood Inst

Natl Inst of Allergy & Infectious Dis

Natl Inst of Child Health & Human Dev

Natl Inst of Dental and Craniofacial Research

Natl Inst of Diabetes, Digest. & Kidney

[9117]

[9119]

[9121]

[9122]

[9123]

[9125]

[9127]

Natl Inst of Environmental Health Science

Natl Inst of General Medical Sciences

Natl Inst of Neurological Disor & Stroke

Nat l Human Genome Research Institute

National Institute of Nursing Research

National Institute on Aging

Natl Inst on Alcohol Abuse & Alcoholism

[9129]

[9131]

[9133]

[9135]

[9137]

[9138]

[9143]

Natl

Inst on Arth, Musculo & Skin Dis

Inst on Deafness & Other Commu Dis

Inst on Drug Abuse

Inst on Mental Health

Center for Research Resources

Inst of Biomedical Imaging and Bioengineering

Inst of Health (Inst not known)

[9103]

[9105]

[9107]

[9109]

[9111]

[9113]

[9115]

Other United States Fe deral Government Agency

Centers for Disease Control

Dept of Defense

Dept of Education

Dept of Energy

Dept of Health & Human Services

Dept of Labor

[9213]

[9215]

[9217]

[9219]

[9221]

[9223]

Environmental Protection Agency

Food and Drug Administration

Health Resources & Svcs Admin

Natl Inst of Occupational Safety

Natl Aeronautics & Space Admin

Agency for Health Care Policy Research

[9225]

[9227]

[9229]

[9235]

[9237]

[9299]

National Library of Medicine

National Science Foundation

Rehabilitation Services Admin

U.S. Public Health Service

Natl Inst of Disability Rehab. Research

Other Federal Government Agency

[9202]

[9203]

[9205]

[9207]

[9209]

[9211]

Other Government, Private Donor, or Academic Institution

Affiliated University

Private Donor

Local Government

[9307]

[9309]

[9311]

State Governm ent

Foreign Government

SWOG

[9360]

[9399]

VA Medical Care Supported Mgmt. Studies

Other Government or Academic

[9301]

[9303]

[9305]

Private Proprietary Company

A.H. Robins

Abbott

Adria

Alpha Therapeutic

American Cyanamid

Ayerst

Amgen

Beecham

Berlex

Boehringer Ingelheim

Boots

Bristol-Meyers Squibb

Burroughs Wellcome

Centocor

Ciba-Geigy

Cytogen

[9725]

[9729]

[9731]

[9732]

[9733]

[9734]

[9736]

[9738]

[9740]

[9742]

[9744]

[9745]

[9746]

[9748]

[9750]

Du Pont

E.R. Squibb

Eli Lilly

Fujisawa

G.D. Searle

G.H. Besselaar

Genentech

Glaxo

Hoechst-Roussel

Hoffman-La Roche

Hybritech

Immunomedics

Janssen

Knoll

Lederle

[9752]

[9754]

[9756]

[9758]

[9760]

[9762]

[9764]

[9766]

[9768]

[9770]

[9773]

[9775]

[9776]

[9777]

[9778]

Lorex

Marion-Merrell Dow

Mc Neil

Mead Johnson

Merck & Co.

Merrell-Dow

Miles

Proctor & Gamble

Organon

Ortho

Parke-Davis

Pfizer

Purdue Frederick

Roberts Pharm

Roche

[9779]

[9781]

[9782]

[9783]

[9784]

[9785]

[9787]

[9789]

[9791]

[9792]

[9793]

[9795]

[9797]

[9798]

[9799]

Rhone-Poulenc Rorer

Ross

R.W. Johnson Pharm

Sandoz

Schering

SmithKline Beecham

Sanofi-Aventis

Stuart

Syntex

TAP Pharm

Upjohn

Warner-Chilcott

Wyeth-Ayerst

Zeneca

Other Private Proprietary Company

[9701]

[9703]

[9705]

[9707]

[9708]

[9709]

[9710]

[9711]

[9712]

[9713]

[9715]

[9717]

[9719]

[9720]

[9721]

[9723]

Voluntary Agency/Foundation (For Local Chapters of National Organizations, use Agency/Foundation code)

Alzheimer's Dis & Related Dis Assoc

American Cancer Society

American Diabetes Association

American Fed for Aging Research

American Fndn for AIDS Research

American Heart Association

American Kidney Foundation

American Legion

American Lung Association

American Narcolepsy Association

Amer Parkinson Disease Assoc

[9823]

[9827]

[9831]

[9833]

[9837]

[9839]

[9843]

[9847]

[9851]

[9855]

[9859]

Arthritis Foundation

Council for Tobacco Research

Cystic Fibrosis Foundation

Deafness Research Foundation

Dermatology Foundation

Disabled American Veterans

Epilepsy Foundation of America

Juvenile Diabetes Foundation

Lupus Foundation of America

March of Dimes

Muscular Dystrophy Association

[9863]

[9867]

[9871]

[9875]

[9879]

[9883]

[9885]

[9887]

[9891]

[9895]

[9899]

National Dairy Council

Natl Foundation Ileitis & Colitis

National Kidney Foundation

National Multiple Sclerosis Society

Paralyzed Veterans of America

Robert Wood Johnson Foundation

Scleroderma Foundation

Smokeless Tobacco Research Council

Spinal Cord Society

Va Private Research Corporation

Other Voluntary Agency \Foundation

[9803]

[9805]

[9809]

[9811]

[9812]

[9813]

[9815]

[9817]

[9819]

[9821]

[9822]

None (Enter 0000) (Use only Administrative Code 01.)

ADMINISTRATIVE CODES

[01]

[02]

[03]

[04]

[05]

No Funding (Valid only for Funding Code 0000)

VA Funds (Valid only for Funding Codes beginning with 90)

VA - Reimbursed from another Federal Agency*

VA - Direct Grant

VA - General Post Funds

[06]

[07]

[08]

[09]

VA - Private Research Corporation

Affiliated University

Other

Med Care-Supported Studies*

*Administrative Code 03 is valid only for Funding Codes beginning with 91 and 92.

*Administrative Code 09 is valid only for Funding Code 9360.

Revised: September 2009

ePROMISe

Page1

Request to Review Research Proposal/Project

561 East Orange, NJ

1. Principal Investigator / Program Director: ______

Last

First

Degree

2. CID: ______

5. VA Appointment:

(Check one)

3. Telephone: ______Ext. ______

Part-Time

WOC

4. Mail Code: ______

Contract

Full-Time

Consultant

6. Status of PI in Proposal: ______

(Enter Code)

(01 = Awardee or Initiator 02 = Not Awardee; i.e., Participant in VA Co-Op Study)

7. Type of Submission:

(Check one)

New

Renewal of Active Project

Yes

If Renewal, complete a and b: a) Enter 4-digit number of active project : _____ b) Has title changed?

(142 characters max)

8. Project Title: ______

______

9. Co-Principal Investigators: (Enter only if study is funded. Must have a VA appointment and must be designated a Co-PI application.)

______

Last name, first name, mi, degree

______

CID

Check if at another VAMC

______

Last name, first name, mi, degree

______

CID

10. Anticipated Starting Date: ______/ ______/ ______(mm/dd/yy)

11. Funding Source and Fund Administration: (Codes are on back of instruction sheet)

Source Code

(4-digits)

______

Name if Source Code ends in “99”

______

Admin Code

(2-digits)

______

Name if Admin Code is “08”

______

If Source Code is 9022, 9024, or 9025, enter VACO Project Number:

______

12. Project Use: (Mark each item and submit completed forms. If Animal Subject is Yes, complete Item 15.)

Human Subjects

Invest Drugs

Animal Subjects

Yes

Exempt

Invest Device

Radioisotopes

Yes

Biohazards

Yes

13. Project Focus: (Mark each item.)

Agent Orange

Children

Yes

Females

Prisoners

Yes

Prisoners of War

International

Yes

14. Keywords: (Minimum 3, maximum 6, MeSH terms only. Enter one tern per line.)

1) ______

2) ______

3) ______

4) ______

5) ______

6) ______

15. Animal Subjects: (Species and, if applicable, strain. Enter one species per line.)

1) ______

5) ______

2) ______

6) ______

3) ______

7) ______

4) ______

8) ______

9) ______10) ______

13) ______14) ______

Revised: September 2009

11) ______12) ______

15) ______16) ______

(Continue on Page 3)

ePROMISe

SUBMIT ORIGINAL FORM. DO NOT COPY.

Page 2

16. Abstract: (Submit on separate sheet or on floppy disk; see instructions )

17. Institutional Support: (Mark each item. *If Yes, a letter of support/collaboration must be attached to this form.)

Laboratory*

Radiology*

Psychiatry*

Other*

Lab Space

Budget Page

Yes

Medicine*

Nuclear Medicine*

Out Patient*

Yes

Pharmacy*

Nursing*

Surgery*

Yes

> If Yes, Specify ______

> If Yes, Bldg and Room ______

> Must be included with all submissions (except Funding Source Code 0000)

18. Institutional Approvals: (signatures as appropriate)

Section Chief ______

Service Chief ______

______

Date

______

Date

19. Comments: ______

______

Principal Investigator ______

Signature

______

Date

Note: If this is your first research proposal submitted at this Medical Center, please also submit an Investigator Data Sheet (Page 18)

and a Personal Data Form. The same applies to co-principal investigators who have not submitted these forms.

Research Office use only:

Date Received : ______

Item checked: 1

VAF 10-5368

Date Returned : ______

Date Entered :

______

Reason: ______

Page 3

ePROMISe