PHS 398-Regular



UM Cardiovascular Center |LEAVE BLANK—FOR CVC RESEARCH REVIEW COMMITTEE USE ONLY. | |

|RESEARCH REVIEW COMMITTEE |Grant Deadline |Grant Resubmission |

|McKay Grant Application |Review Date |Date Received |

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|TITLE OF PROJECT |

|CHECK TYPE OF APPLICATION OUTCOMES BASIC SCIENCE | |

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|PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR NAME (Last, first, middle) |DEGREE(S) |

|POSITION TITLE |E-MAIL: |

|SECTION |TELEPHONE: |

|UNIVERSITY MAILING ADDRESS |FAX: |

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|CO-INVESTIGATOR NAME |CO-INVESTIGATOR DEPARTMENT & SECTION |

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|HUMAN SUBJECTS |If “Yes”, IRB approval date: |ANIMALS |If “Yes”, UCUCA approval date: |

|No | |No | |

|Yes | |Yes | |

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|DATES OF PROPOSED PERIOD OF SUPPORT (month, |From |Through |Costs requested: |

|day, year—MM/DD/YY) | | | |

| | |

|Use of radioisotopes in or on humans No Yes |If yes, date of committee approval: |

|Use of radioactive materials No Yes |If yes, date of RPC approval: |

|Use of recombinant DNA No Yes |If yes, specify: |

|Use of human body substances No Yes |If yes, specify: |

|Use of etiologic agents No Yes |If yes, specify: |

|Use of proprietary materials No Yes |If yes, specify |

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|FOR REVIEW COMMITTEE USE ONLY: (Assigned Reviewer) |FOR REVIEW COMMITTEE USE ONLY: (Assigned Reviewer) |

|Name |Name |

|Address |Address |

|Telephone |Telephone |

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| |Ann Arbor, MI 48109-1274 |

|FAX |FAX |

|E-Mail |E-Mail |

|PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE: |SIGNATURE OF PI/PD |DATE |

|I certify that the statements herein are true, complete and accurate to the best of my | | |

|knowledge. I am aware that any false, fictitious, or fraudulent statements or claims | | |

|may subject me to criminal, civil, or administrative penalties. I agree to accept | | |

|responsibility for the scientific conduct of the project and to provide the required | | |

|progress reports if a grant is awarded as a result of this application. | | |

|SECTION HEAD/DIVISION CHIEF OR DEPARTMENT CHAIR PRINTED NAME |SIGNATURE SECTION HEAD/DIVISION CHIEF OR DEPARTMENT CHAIR |DATE |

| |(required) | |

DESCRIPTION. State the application’s broad, long-term objectives and specific aims, making reference to the health relatedness of the project. Describe concisely the research design and methods for achieving these goals. Avoid summaries of past accomplishments and the use of the first person. This description is meant to serve as a succinct and accurate description of the proposed work when separated from the application. If the application is funded, this description, as is, will become public information. Therefore, do not include proprietary/confidential information. Do not exceed the space provided.

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|PERFORMANCE SITE(S) (organization, city, state) |

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KEY PERSONNEL. Use continuation pages as needed to provide the required information in the format shown below.

Name Organization Role on Project

Type the name of the principal investigator/program director at the top of each printed page and each continuation page. (For type specifications, see

instructions on page 6.)

CVC McKay RESEARCH COMMITTEE

RESEARCH GRANT

table of contents

Page Numbers

|Face Page |1 |

|Description, Performance Sites, and Personnel – |2 |

|Table of Contents |3 |

|Detailed Budget for Initial Budget Period |4-5 |

|Biographical Sketch-Principal Investigator/Program Director (Not to exceed two pages) |6-7 |

|Other Biographical Sketches (Not to exceed two pages for each) |8-9 |

|Other Support |10 |

|Resources |11 |

Research Plan

|Introduction to Revised Application (Not to exceed 3 pages) | |

|Introduction to Supplemental Application (Not to exceed 1 page) | |

|a. Specific Aims (Items a-d not to exceed 6 pages) | |

|b. Background and Significance (Items a-d not to exceed 6 pages) | |

|c. Preliminary Studies (Items a-d not to exceed 6 pages) | |

|d. Research Design and Methods (Items a-d not to exceed 6 pages) | |

|e. Human Subjects | |

|f. Vertebrate Animals | |

|g. Literature Cited | |

|h. Consortium/Contractural Arrangements | |

|i. Consultants | |

|DETAILED BUDGET FOR INITIAL BUDGET PERIOD |FROM |THROUGH |

|DIRECT COSTS ONLY | | |

|PERSONNEL (Applicant organization only) | |% | |DOLLAR AMOUNT REQUESTED (omit cents) |

| | |TYPE |EFFORT |INST. | | | |

| |ROLE ON |APPT. |ON |BASE |SALARY |FRINGE | |

|NAME |PROJECT |(months) |PROJ. |SALARY |REQUESTED |BENEFITS |TOTALS |

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|[pic] | | | |

|CONSULTANT COSTS | |

|EQUIPMENT SUPPLIES (Itemize by category) | |

|SUPPLIES (Itemize by category) | |

|TRAVEL | |

|PATIENT CARE COSTS |INPATIENT | |

| |OUTPATIENT | |

|ALTERATIONS AND RENOVATIONS (Itemize by category) | |

|OTHER EXPENSES (Itemize by category) | |

|TOTAL COSTS FOR BUDGET PERIOD | |

BUDget justification:

          

|BIOGRAPHICAL SKETCH |

|Provide the following information for the key personnel in the order listed for Form Page 2. |

|Follow the sample format on preceding page for each person. DO NOT EXCEED FOUR PAGES. |

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|NAME |POSITION TITLE |

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

|INSTITUTION AND LOCATION |DEGREE |YEAR(s) |FIELD OF STUDY |

| |(if applicable) | | |

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Other support:

RESOURCES

FACILITIES: Specify the facilities to be used for the conduct of the proposed research. Indicate the performance sites and describe capacities, pertinent

capabilities, relative proximity, and extent of availability to the project. Under “Other,” identify support services such as machine shop, electronics shop, and specify the extent to which they will be available to the project. Use continuation pages if necessary.

|Laboratory: |

|Clinical: |

|Animal: |

|Computer: |

|Office:       |

|Other: |

MAJOR EQUIPMENT: List the most important equipment items already available for this project, noting the location and pertinent capabilities of each.

A. SPECIFIC AIMS

B. BACKGROUND AND SIGNIFICANCE

C. PRELIMINARY STUDIES

D. RESEARCH DESIGN AND METHOD

E. HUMAN SUBJECTS

F. VERTEBRATE ANIMALS

G. LITERATURE CITED

H. COLLABORATORS

I. CONSULTANTS

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