University of Kansas Medical Center Research Institute

PROPOSAL ROUTING SHEET

DEADLINE:Date/Time Received______SPA Proposal #______

PROJECT PERIOD: FROM TO Solicitation/Funding Opportunity#

P.I. INDICATE ONE: ___ 10- business day FINAL ____ 10-business day DRAFT Research Plan/Technical Section ___ 5-business day FINAL

Top of Form

Principal Investigator (Last Name, First Name) / Contact Name/Phone# / E-Mail Address
PI's Department / Administering Dept/Center (F&A Return Dept/Center)
Project Location (Room and Building) / KUMC Centers
Related Select:SelectCardiovascular Research InstituteCenter for Biostatistics and InformaticsCenter for Child Health and DevelopmentCenter for Health InformaticsCenter for TeleMedicine and TeleHealthCenter on AgingGeneral Clinical Research CenterHeartland Inst for Clinical and Translational ReHogland Brain Imaging CenterIMOMInst Reproductive Health & Regenerative MedicineInterdisciplinary Ctr for Male Contraceptive & DDKidney InstituteKU Cancer CenterKU Diabetes CenterLiver CenterProgram in Integrative MedicineSmith Intellectual & Devel Disabilities Research
If funded, will project activity require additional space/facilities currently not available to the PI? Yes No
(If yes, attach letter to appropriate Dean explaining in detail space/facilities requested)
Are you using Clinical Trial Administration services? Yes No
YES NO Data retention/sharing requirement? If yes, estimated: gigabyte terabyte
Project Title:
Major Goals: (Limited to two or three lines):
Funding Agency/Institution / Original Source of Funding (if KUMC is the subcontractor)

Bottom of Form

Project Type: Basic Research T1 T2Clinical Trial Clinical ResearchTraining&EducationServiceOther (Check all that apply)

Proposal Type:New Transfer Competing Renewal Revision/Resubmission Subcontract Continuation/Supplement to Acct #

Does the proposal include Cost Sharing or Matching Funds? No Yes (Attach Chairs, Dean’s or Ctr. Director’s Letter of Commitment)

Key Personnel:

Name / Department Name / Project Role / Effort Committed / Cost Share Effort (if applicable)

Add additional page for key personnel not listed above

DOES THE PROPOSAL INCLUDE ANY OF THE FOLLOWING?

YES NO Human Subjects IRB# Approval Date Exemption # Pending X

YES NO Stem Cells IF YES: Adult Umbilical Somatic Cell Nuclear Transfer Mouse Embryonic Other

Human Embryonic :approved cell line number/Source or / __

i.e. WA01/WiCell

YES NO Vertebrate Animals IACUC # Approval Date Pending

YES NO Select Agents(list)

YES NO Human Tissues/Body Fluids IRB# or not Human Subject DeterminationKUMC Safety Forms: EHS Risk Assessment

YES NO Recombinant DNA Approval Date Please obtain approval from KU EHS Office prior

YES NO Radioisotopes/Radiation Produce Equipment Approval Date to proposal submission (see page 3).

YES NO Biohazards / Hazardous Materials (if yes, attach approval form)

Link to KUMC Office of Compliance 1SPA Proposal Routing Sheet rev 11-11

KEYWORDS

BODY SYSTEMCONDITIONKUMC PROGRAM

Adrenal GlandsAging Alternative Medicine and Research

Arteries Alcoholism Bioengineering

Bladder Alzheimer’s Disease Bioinformatics

Bones Autism Biostatistics

Brain Bacterial Infections Bone

Breast Birth/Parturition Cancer

Cardiovascular System Breast Cancer Clinical and Translational Research

Central Nervous System Cancer Compound Synthesis

Cervix Cardiovascular Disease Diabetes

ColonCongenital Abnormalities Drug discovery

Digestive System Congenital Abnormalities Heart

EarConnective Tissues High throughput Screening

Endocrine SystemCystic Fibrosis Integrative Medicine

EsophagusDiabetes Immunology/Virology

EyeDisease of Blood Kidney

Fetus Disease of Digestive System Liver

Gallbladder Disease of Endocrine System Mass Spectrometry/Proteomics

Gastrointestinal Tract Disease of Ears/Eyes Maternal/Fetal/Child Health

Heart Disease of Genitourinary System Neuroscience/Brain Health

Hypothalamus Disease of Liver Obesity

Joints Disease of Lupus Ophthalmology/Ophthalmic

Kidney Disease of Muscles/Bones/Connective Engineering /Clinical Eye Institute

Larynx Tissue Personalized Medicine

Ligaments Disease of Nervous System Public Health

Liver Disease of Respiratory System Reproductive Sciences/Fertility

Lung Disease of Skin

Lymph Node Heart Disease

MusclesHIV/AIDS

Nerves Infertility/FertilityCOLLABORATIONS

Nervous SystemInjury/Burns

NoseKidney DiseaseAcross Disciplines

OvaryMenopause KUMC and another institution

OvumMuscular Dystrophy KUMC and Stowers

PancreasMental Disorders KUMC and KU-Lawrence

PenisNutrition KUMC and St. Luke’s

Pituitary GlandObesity KUMC and Children’s Mercy

PlacentaParkinson’s Disease KUMC and UMKC

ProstatePregnancy KUMC and Quintiles

Respiratory SystemPoisons/Toxins KUMC and pharmaceutical company

SkinPuberty KUMC and KCUMB

SpermSmoking cessation

SpleenStroke

StomachVascular Disease

TendonsViral Infections

Testis

Thyroid GlandSUBJECT

Tongue NEW CENTER

Uterus Animals

Veins Children - boys

Urinary Tract Children – girls

Drug

Elderly

Gene

TRAINING Hormone

Infants

Conference Institution

Junior Faculty Men

Post Doctorate Pregnant Women

Pre-Doctorate Stem Cells - Adult

Stem Cells – Embryonic

Women

2 SPA Proposal Routing Sheet rev11-11

PI: / PROJECTTITLE:

CERTIFICATION/ASSURANCES

The undersigned certify that neither the PI nor anyone proposed to work on this project are, to the best of their knowledge, excluded from participation in Federally funded activities as a result of government-wide suspension or debarment.

PI/PROJECT DIRECTOR: I certify that the above information submitted within the application is true, complete and accurate to the best of my knowledge. I understand that any false, fictitious, or fraudulent statements or claims may subject the PI to criminal, civil, or administrative penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of the application. This project is in compliance with the KUMC Conflict of Interest Policy. If any project personnel has a potential conflict of interest, financial or otherwise regarding the sponsor of this project, a Conflict of Interest Disclosure Form should be

submitted to the Research Compliance Office.

I understand that NIH requires principal investigators to submit journal articles that arise from NIH funds to the digital archive PubMed Central.

Co-PI: (typed/written)______

______

PI/Project Director’s Signature/Date Co-PI’s Signature/ Date

For Clinical Trials, do any of the investigators, those responsible for obtaining the informed consent of human subjects or any member of their immediate family have any financial interest or other relationship with any company or entity that sponsors or supports this clinical trial?

Yes No PI Initials ______

(Please add additional signature page for multiple PI’s/Co-PI’s project)

DEPARTMENT/CENTER CHAIR: The attached application is approved. It is within the total program and academic objectives of the Department/Institution/Center. Adequate space is available or planned for the conduct of the project. The professional time allocations described therein are approved.

______

Department Chair/Center Director (typed/written)Department Chair’s/Center Director’s Signature Dept. Admin. Initials - BUDGET

APPROVED

______

Collaborating Dept. Chair (typed/written)Collaborating Dept. Chair’s Signature Dept. Admin. Initials

DEAN OF SCHOOL (or Designee): The proposed project is approved. It is consistent with the total program objectives of this school and the commitments for this project.

______

M. Michelle Mariscalco, Associate Dean for Research Trisha Richmeier, DA OoR (Designee for DA budget approval)

KUMC Research Institute Official Signature

______

Associate Vice Chancellor for Research Administration

OTHER APPROVALS

______Jim Bingham, Assoc Vice Chancellor for Info Resources & Chief Info Officer (1014 Eleanor Taylor, Ext 8-4900). Required only for proposals involving computing, telecommunications, telemedicine, internet development, library or computer-based education/training.

______Jon Jackson Senior Vice President, Hospital Executive Office (1215 KU Hospital, Ext 8-1289) required only for proposals using hospital services, facilities, personnel or training programs. Signatures indicate protocol has been reviewed and does not conflict with hospital philosophy or policy.

______Ram Sharma, PhD ,VAMC, KC Assoc. Chief of Staff for Research. Required if VAMC facilities, patients or personnel are committed.

______Richard Couldry (B400 KU Hospital, Ext 8-2330). Required for drug protocols involving investigational Drugs

______Tom Field or Karen Blackwell, KUMC Office of Compliance (1040 Wescoe Pavillion).

______Ryan Lickteig or Shannon Patel, KUMC Environment, Health and Safety Office (G032 Wescoe)

Helpful links: NIH Salary Cap, Information Often Requested on Applications, KUMCRI Policies and Procedures, eRA Commons/Grants.gov

3SPA Proposal Routing Sheet rev11-11