BARNES-JEWISH HOSPITAL FOUNDATION
Siteman Investment Program Research Development Awards
Cover Sheet Form
|Project Title: |
|Clinical Trial |Pre-R01 |Team Science |
| New CT | Established CT | Pre-R01 | Prev & Control | WU/MU Collab | Team Science |
|Contact Principal Investigator (PI) |
|Name (Last, First): |Degree(s): |
|Title: |Organization: |
|Department/Division: |E-mail: |
|For collaborative proposals (SLU/WU or MU/WU): |
|Co-PI Name (Last, First): |Degree(s): |Organization: |
|Title: |Department/Division: |
|Grant Administrator |
|Name: |Phone: |E-mail: |
|Dates of Proposed |Direct Costs Requested for Initial Budget Period |Direct Costs Requested for Proposed Period of |
|Period of Support |(Year 1) |Support |
|MM/DD/YYYY |MM/DD/YYYY |$ direct costs |$ direct costs |
|Please check if either are applicable: |
| SIP Application Re-submission Previously submitted to the NCI/NIH (Summary Statement included) |
|Please check each Siteman Shared Resource being utilized for this project (Letter of Support required for each) |
| Biologic Therapy Core Facility | Biostatistics Shared Resource | Genome Engineering & iPSC Center |
|Genome Technology Access Center |Imaging & Response Assessment Core |Immunomonitoring Laboratory |
|Informatics Core Services |Proteomics Shared Resource |Siteman Flow Cytometry |
|Small Animal Cancer Imaging |Tissue Procurement Core |WU Center for Cellular Imaging |
|Research keywords and major techniques or methods for purpose of assigning reviewers |
| |
|Provide three institutional (WU, SLU, and/or MU) non-conflicted faculty reviewer suggestions |
| | | |
|Lay Language Summary (This summary is provided to the public if awarded and should be written in non-scientific terminology. Failure to provide an adequate lay |
|summary may result in delayed funding. Up to 250 words – text box will expand) |
| |
|Institutional Approvals & Related Questions |
|Indicate percentage between “lab/bench” and “clinical/other” for this project. This should directly reflect budgeted expenses, as administration will use it to |
|calculate indirect costs post-award. |
|Lab/Bench: % Clinical/Other: % |
|Indicate institutional approvals that are required for this project: |
|Live Animals Human Subjects Human Embryonic Stem Cells Radioactive Materials Recombinant DNA |
|Human Subjects |YES |NO |
|Is this proposal funding clinical research? | | |
|Is this proposal funding an interventional clinical trial (as defined by the NIH, see RFA)? | | |
|Is this proposal funding a correlative study on a clinical trial? | | |
| | | |
|Inventions |YES |NO |
|Do you anticipate any inventions, patents, and/or licenses resulting from this proposal? | | |
| | | |
|International & Export Controls |YES |NO |
|Does this project have an international component? | | |
|Will any technology or technical information used or developed in connection with this research have an identified military | | |
|application? | | |
|To your knowledge has any aspect of this project been designated by the NIH as export-controlled under the federal Export Control Laws?| | |
|PI Certification and Acceptance |
|I certify that the statements herein are true, complete and |SIGNATURE OF PRINCPAL INVESTIGATOR |DATE |
|accurate to the best of my knowledge, and accept the obligation |Electronic signature accepted | |
|to comply with the terms and conditions if a grant is awarded as| | |
|a result of this application. I am aware that any false, | | |
|fictitious, or fraudulent statements or claims may subject me to| | |
|administrative penalties. | | |
|Official Signing for Applicant Organization (Not Required for WU or MU Applicants; For SLU Use Only) |
|Name: |SIGNATURE OF OFFICIAL NAMED |
| |Electronic signature accepted |
| | |
|Title: | |
|Organization: | |
|Phone: |DATE |
| | |
|E-mail: | |
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