Principal Investigator/Program Director (Last, First, Middle):

UCSD Clinical and Translational Research Institute: Pilot Project Proposal Form – Phase 1

1. PROJECT TITLE
2a. PRINCIPAL INVESTIGATOR
Last name / First Name / Degree
E-mail / Phone
ERA COMMONS name:
A.Institution
 UCSD Other (please specify) / Department:
B.Faculty Rank
 Assistant Professor  Associate Professor
 Full Professor  Other / If “Other,” please specify:
C.CTRI Membership
 General Associate Not a member / D.Currently supported by NIH Career Development or Training Award
 Yes No
2b. Co- INVESTIGATOR [NOTE: FILL OUT FOR ALL CO-INVESTIGATORS]
Last name / First Name / Degree
E-mail / Phone
A.Institution
 UCSD Other (please specify) / Department:
B.Faculty Rank
 Assistant Professor  Associate Professor
 Full Professor  Other / If “Other,” please specify:
C.CTRI Membership
 General Associate Not a member / D.Currently supported by NIH Career Development or Training Award
 Yes No
3. Administrative contact information
Last name / First Name
E-mail / Phone
4. Pilot Grant Application for / 5. Previous CTRI Pilot Awards
A.  Pilot Clinical Studies
B.  Pilot Translational Studies
C. Pilot Innovative Technology Projects
D. Seed grants for community researchers / Previously funded for CTRI Pilot Grant
A.  Pilot Clinical Studies ______year
B.  Pilot Translational Studies ______year
C. Pilot Innovative Technology Projects ______year
D. Seed grants for community researchers ______year
6. Grant Proposals with Full Professors
If PI, please explain how this work differs from your previous work:
If Co-investigator, please explain your role in this project:
7. Suggested Reviewers with email addresses:
7. PROJECT DESCRIPTION (500 words or fewer)

BIOGRAPHICAL SKETCH

Provide the following information for the key personnel and other significant contributors in the order listed on Form Page 2.
Follow this format for each person. DO NOT EXCEED FOUR PAGES.
NAME / POSITION TITLE
eRA COMMONS USER NAME
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)
INSTITUTION AND LOCATION / DEGREE
(if applicable) / YEAR(s) / FIELD OF STUDY

Personal statement

A. Positions and Honors

B. Fifteen Selected peer-reviewed publications relevant to the current proposal

C. Research Support

Ongoing Research Support

Pending

DETAILED BUDGET FOR INITIAL BUDGET PERIOD

DIRECT COSTS ONLY

/ FROM / THROUGH

List PERSONNEL(Applicant organization only)

UseCal, Acad, or Summer to Enter Months Devoted to Project

Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits

NAME / ROLE ON
PROJECT / Cal.
Mnths / Acad.
Mnths / Summer
Mnths / INST.BASE
SALARY / SALARY
REQUESTED / FRINGE
BENEFITS / TOTAL
PD/PI
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
INPATIENT CARE COSTS
OUTPATIENT CARE COSTS
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
CONSORTIUM/CONTRACTUAL COSTS / DIRECT COSTS
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page) / $
CONSORTIUM/CONTRACTUAL COSTS / FACILITIES AND ADMINISTRATIVE COSTS
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD / $

PHS 398 (Rev. 6/09)Page