Indiana CTSI - Devices Advancing Surgical & Interventional Care

Indiana CTSI - Devices Advancing Surgical & Interventional Care

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PRINCIPAL INVESTIGATOR:

RANK / TITLE:

DEPARTMENT and SCHOOL:

INSTITUTION / AFFILIATION: IUB IUPUI IUSM PURDUE UND IU Regional Campus IBRI

CAMPUS ADDRESS:

EMAIL:eraCOMMONS USERID:

ADDRESS WHERE WORK WILL BE PERFORMED:

PRINCIPAL INVESTIGATOR:

RANK / TITLE:

DEPARTMENT and SCHOOL:

INSTITUTION / AFFILIATION: IUB IUPUI IUSM PURDUE UND IU Regional Campus IBRI

CAMPUS ADDRESS:

EMAIL:eraCOMMONS USERID:

ADDRESS WHERE WORK WILL BE PERFORMED:

TITLE OF PROPOSAL:

RESUBMISSION: YES NO

If yes, please address the comments from the previous review in the research plan section.

TOTAL BUDGET PERIOD:

From: (Month/Day/Year)To: (Month/Day/Year)

TOTAL AMOUNT REQUESTED: $

APPROVAL

YES NO PENDINGPROTOCOL # DATE

RECOMBINANT DNA?

HUMAN SUBJECTS?

VERTEBRATE ANIMALS?

REQUIRED SIGNATURES: The undersigned agrees to accept responsibility for the scientific and technical conduct of the research project and for provision of required progress reports if a grant is awarded as the result of this application. Funding for this award will be provided by the sponsor, Indiana University Health, and the prime sponsor, Cook Medical, Inc. and should be considered an external funding award. Therefore please ensure appropriate institutional review.

APPLICANT SIGNATURE: ______

IUSM
Department Head / Chair(1)

(1)Departments of Medicine and Pediatric: Division Chief Signature is requested in lieu of the Department Chair. Institutional Official

Signature is not required.

IUB, IUPUI
Department Head / Chair
IBRI / Signature and Date
Applicant
Chief of Staff/ Executive Vice President
Purdue University
Department Head / Chair
Institutional Official(1)

(1)Signature approval by any Sponsored Program Services (SPS) Pre-Award Center Manager is required by Purdue University applicants.

University of Notre Dame / Signature and Date
Applicant
Department Head / Chair

Indicate intent to submit to Melanie DeFord via email ().
Must work with your pre-award research administrator.
Institutional routing is not required; however investigators must answer the compliance questions in Cayuse.

If you have any questions, contact Richard Hilliard () or Melanie DeFord ().

Principal Investigator/Program Director (Last, first, middle):

DETAILED BUDGET FOR INITIAL BUDGET PERIOD
DIRECT COSTS ONLY / FROM / THROUGH
PERSONNEL (Applicant organization only) / % / DOLLAR AMOUNT REQUESTED (omit cents)
NAME / ROLE ON
PROJECT / TYPE
APPT.
(months) / EFFORT
ON
PROJ. / INST.
BASE
SALARY / SALARY
REQUESTED / FRINGE
BENEFITS / TOTAL
Principal
Investigator
Collaborator
SUBTOTALS
CONSULTANT COSTS
SUPPLIES
TRAVEL
PATIENT CARE COSTS
OTHER EXPENSES

TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD

BUDGET JUSTIFICATION (½ page):

Principal Investigator/Program Director (Last, first, middle):

TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD

BUDGET JUSTIFICATION (½ page):

Principal Investigator/Program Director (Last, first, middle):

RESEARCH PLAN (Not to exceed 3single-spaced pages excluding references):

Principal Investigator/Program Director (Last, first, middle):

BIOGRAPHICAL SKETCH

Provide the following information for the Principal Investigator. DO NOT EXCEED FOUR PAGES.

NAME / POSITION TITLE
eRA COMMONS USERNAME

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training and residency training if applicable.)

INSTITUTION AND LOCATION / DEGREE
(if applicable) / MM/YY / FIELD OF STUDY

Personal Statement

Positions and Honors

Selected Peer-reviewed Publications

Research Support

Please refer to NIH PHS398 application instructions document for information on completing the biographical sketch pages. If this template does not reflect the current PHS 398 form, the current forms can be used in place of the templates provided here, for the Biosketch only.