PETER MORGANE RESEARCH FELLOWSHIP

APPLICATION FORM

Deadline for submission: April 11, 2016

Applicant Information
Name: / Class Year: / Email:
Have you received Peter Morgane Research fellowship (Formerly known as UNECOM Dean’s Research Fellowship) before? Yes No / If Yes, which year(s):
Primary Mentor Information
Name: / Title: / UNE affiliation or home institution:
Phone: / Email: / Fax:
Project Information
Title of the Project:
Key words (Specific words or phrases that can be used to index your research project; no more than 6):
Performance Site (Room/building, Institution, City, State):
Will human or animal subjects be used in the project? Human Animal N/A
Note: All personnel have to complete the required CITI training prior to participating in the proposed project.
Has the required protocol been approved by either IRB or IACUC? Yes No / If Yes, please provide the protocol #: / If No, please explain (i.e., review pending or to be submitted):
Please list all required training that needs to be completed in order to conduct the project (please consult with your mentor) and the status for each (completed or will be completed by):
e.g., at UNE, the “Laboratory Safety Training” is required for everyone who works in a research laboratory.
Note: All training courses have to be completed by the date(s) specified below in order for a fellowship recipient to receive payment.
1.  MSUCOM Research Training - by June 5, 2016
2.  CITI online training modules for research with human subjects or animals (if appropriate) – by June 5, 2016
Please continue the list with additional required training identified by your mentor:
3. 
AGREEMENT REGARDING FUNDS RECEIVED AS A RESULT OF THIS APPLICATION
The undersigned agree:
1. To complete the project as outlined herein and fulfill all requirements outlined in Section V in “INSTRUCTIONS FOR APPLYING FOR THE PETER MORGANE RESEARCH FELLOWSHIP 2016”.
2. To observe institutional responsibilities concerning the protection of animal or human research subjects.
3. To follow all training requirements and related institutional policies when conducting a research project at a selected institution.
Applicant Signature: / Date:

Research Proposal – Please refer to Section II-B in “INSTRUCTIONS FOR APPLYING FOR THE PETER MORGANE RESEARCH FELLOWSHIP 2016”. Please use “Times New Roman” Font 11 and DO NOT exceed the space limitations indicated for each section.

1.  Background/Significance and Specific Aims (up to one page)

2.  Experimental Approach (up to 1¾ pages)

3.  Time Line of the Project (up to ¼ page)

4.  Literature Cited (not exceed one page)

ADDITIONAL MATERIALS:

·  Applicant CV

·  Primary Mentor’s Letter of Support

·  Primary Mentor’s Agreement

·  Primary Mentor’s CV or NIH Biosketch

Please include all documents for the primary mentor followed by all documents for the co-mentor (if applicable)

APPLICATION SUBMISSION:

Deadline is mid-night April 11, 2016

All application materials must be submitted as a single PDF file and sent electronically to:

1

Revised 2/19/2016