Date: / Date Received:
1. TITLE OF PROJECT
2. PRINCIPAL INVESTIGATOR
2a. Name (Last, first, middle)
2b. Telephone: / 2c. e-mail:
2d. Department/Division:
2e. Classification: Physician Staff Nursing Staff Nursing Trainees Research Fellow/Post Docs
Clinical Fellows Resident/Intern Other
If resident, fellow, or trainee, enter date training period begins: ends:
2f. MMC Employee? Yes No If No, please specify:
2g. Research mentor name (If applicable): Email Phone
3. CO-INVESTIGATOR Yes No If yes, please fill out question 3 information.
3a. Name (Last, first, middle)
3b. Telephone: / 3c. E-mail:
3d. Department/Division:
4. PROJECT INFORMATION
4a. Project period: from (MMDDYY) through (MMDDYY)
4b. Will this study be collaboration with other MMC departments? Yes No If yes, department name
Please attach a description of the collaboration and letters of support
4c. Will this study be collaboration with outside Institutes or companies? Yes No
If yes, institute/department name Please attach a description of the collaboration and letters of support
of the collaboration in the Research Plan (including letters of support).
5. FUNDING
5a. Are you seeking funding through the Mentored Research Committee? (Open to clinical research and nursing trainees)
Yes No If yes, please complete sections A and B of this application.
5b. Are you seeking funding from the RSP or NSI? (Open to Faculty and Staff)
Yes No If yes, please complete sections A and C of this application.
6. Human or Animal Subjects
Humans Yes No Animals Yes No
Principal Investigator/Sponsor Assurance: I accept responsibility for the conduct of all aspects of this study. No changes to the Research Plan will be made without approval of the Chairman of the Scientific Review Committee, the Institutional Review Board (if human subjects are involved), or the Institutional Animal Care & Use Committee (if animals are involved). If I received funding for this study, I will submit semiannual progress and financial reports and copies of any reports published on the basis of this award.
______
Signature of Principal Investigator Print Name Date
I have reviewed and hereby endorse this proposed research project:
______
Signature of Department Chief /Authorized Official Print Name Date
I have reviewed this research project and accept the role as mentor to the investigator and project. I also accept responsibility for ensuring the timely submission of progress and financial reports to the Committee for review. (If applicable)
______
Signature of Mentor Print Name Date