Global Health

Module Questions

Organization Legal Name: / Submission Date:
Project Title:
Primary Contact:
Email Address for Primary Contact:

Rev. 6/09

Global Health Letter of Inquiry

Application Form

General Questions

Please answer the following questions to the best of your ability. Your answers to these questions will help the foundation determine if you need to complete a separate module in addition to your proposal. It will have no bearing on whether the foundation will decide to approve or decline your request.

Global Health Letter of Inquiry

Application Form

Will the project involve research using human subjects1 and/or vertebrate animals? / YES NO
Will the project involve a clinical trial2? / YES NO
Will the project involve the use of recombinant DNA? / YES NO
Will the project involve the use of biohazards or genetically modified organisms or plants? / YES NO
Will the project involve the use of pathogens/toxins identified as select agents3 by U.S. law? / YES NO

Global Health Letter of Inquiry

Application Form

Global Health Letter of Inquiry

Application Form

For definitions, please review the following: 1human subjects; 2clinical trials; 3select agents

Will your project involve the creation of a new technology, formulation, product or medical procedure, or the further development of any existing technology, formulation, product or medical procedure? / YES NO
Will your project involve the use of technology, a product, material or data owned or to be provided by a third party? / YES NO
Will your project involve the creation of software, drawings, or written material (such as an analysis, a curriculum, guidelines, policy recommendations) other than internal working documents, reports to the foundation, or publications? / YES NO
Will the project involve outreach to health and non-health sector policy makers/leaders on political, financing, policy or media issues (i.e. those issues relating to the positioning of global health in the broader development agenda)? / YES NO
Will the project involve the use of the media or other public platforms to educate or inform about specific global health issues? / YES NO
Will the project involve work with high-profile individuals (community leaders, celebrities, etc.) as spokespeople or representatives? / YES NO
Will the project involve Activities being conducted in countries where U.S. embargoes (Cuba, Sudan, Iran) or significant economic restrictions apply (e.g. North Korea, Myanmar, Syria)? / YES NO
Will the success of the project depend on large-scale policy change at the national or international level (e.g., new WHO recommendation, changing national treatment guidelines)? / YES NO