University of Minnesota Obesity Prevention Center (OPC)

Internal Review Form (IRF) for Competing Research Proposals

Date:

Please complete all of the following information.

NOTE: Approval form must be submitted to UMOPC at least 8 weeks prior to proposal deadline.

1.Principal Investigator:

2.Agency/Sponsor:

3.Agency Deadline:

  1. If this is a Subcontract, please indicate name of prime institution:
  1. Grant/Contract Title: (Not to exceed 81 typewriter spaces, including spaces between words and punctuation for NIH grants.)

6.Type of Submission: Please check one and complete additional information requested.

a. New:If in response to an RFA/PA, please indicate RFA/PA# here: (Attach copy of RFA/PA instructions to this form.)

b. Revised:Agency # assigned from initial submission:

c. Supplement to existing grant: Agency#: CUFS #:

d. Renewal: Agency#: CUFS #:

7. Dates of Entire Proposed Project Period: Start Date: End Date:

8.List Names of Collaborating Faculty and University Departments:

9. List Subcontract/Consortium Agreements (if applicable):

a. Institution/Principal Investigator/Phone#:

b. Institution/Principal Investigator/Phone#:

c. Institution/Principal Investigator/Phone#:


10.List Consultants (list full names and affiliation):

11.Human Subjects: Does this project involve human subjects?

a. Yes b. No

If YES, what is the status of the Human Subjects Application?

Approved:

Exempt: Exemption Category:

Study Code Number:

Approval Date:

Pending:

12.Space Requirements: For planning and budgeting purposes, please indicate whether sufficient space is currently available for this project:

a. Current space is sufficient:Yes No

b. An additional number of cubicles/offices will be needed (please explain):

c. Epidemiology Clinical Research Center (ECRC) space is requested:Yes No

NOTE: If you are proposing to use the ECRC, you must first email Dr. Kristine Ensrud () prior to submission. If space will not be available at the ECRC, and you need off-site clinic space, you will need to include space rental in your proposal budget and this will affect the Facilities and Administration rate used.

13.Abstract/Description of Proposal (must be attached):

Please attach the abstract or a brief description of the proposal to this form.

Principal Investigator Signature

Signature Date

I have reviewed the scientific merit of this project and it is within the goals and mission of the University of Minnesota Obesity Prevention Center.

UMOPC Director

Robert W. Jeffery, Ph.D.

Signature Date

Senior Vice President,

Academic Health Center

Frank B. Cerra, M.D.Signature Date Date

Dean,

School of Public Health

John R. Finnegan Jr., Ph.D.Signature Date

Cc:Dr. Bernie Harlow

Anne Everett

Char Flipp

Kerrin Brelje

Sally Miles

Dean Finnegan

Dr. Frank Cerra

Dr. Robert Jeffery Date Date

Revised 10/9/2018Page 1