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Please submit entire application as single pdf file, either by completing electronically and converting to pdf format OR by printing, completing, and scanning into a pdf file. The completed application must be submitted as a single pdf file at website: .

Deadline: Submissions uploaded after the submission deadline (Midnight, Sunday, April 15, 2013) will not be considered. Applications cannot be more then 3 pages.

1. Application categories

Principal investigator name and degrees:

Project title:

Which review panel would be most appropriate for reviewing your application (check one)?

Basic research, animal models, early translational research

Clinical, epidemiologic, and health services research; translational human clinical studies

Has an application for extramural funding has been previously submitted for this topic?

No

Yes ( if yes, please specify:

Funding agency:       Please check if already reviewed:

If reviewed, please attach review to the application form.

2. Proposal summary

Principal investigator information

Principal Investigator (Last name, first name, MI):

Academic Appointment:

Department / Section:

Area of research expertise:

PI Phone Number: PI Fax: PI email:

PI eRA commons user name:

Financial Administrator:

Administrator phone number: Administrator email:

(Note: Pilot award funding will be administrated by the awardee’s administrator. This contact information should be for the person who will be responsible for financial administration of the award.)

Project Information

Project title:

Effective dates of project (MM/DD): From to [To be determined - Please leave dates blank]

Key Personnel in Addition to PI (name/degrees/school/ dept/ division or section:

2. Proposal summary (continued)

Budget for Proposed Year

Budget:

Salaries and Wages

Fringe Benefits

Consultants

Consumables

Travel

Equipment

Total Direct Costs:

NO INDIRECT COSTS ARE AWARDED.

3. Detailed Budget

Principle Investigator:

Grant Project Title:

Budget Start/End Date:

Personnel Budget (Note: PI and co-investigator salary may not be requested)

|Name |Role |Annual |% Effort |Project Period |Salary |Fringe |Total |

| | |Salary | |(months) | |Benefits | |

| | | | | | | | |

|      |      |      |      |      |      |      |      |

| | | |

|Consultants |      |      |

|      | | |

|Consumables/Other Expenses | | |

|      | | |

| | | |

|Travel |      |      |

|      | | |

|Equipment |      |      |

|      | | |

| | | |

| |Total Consumables and Other: | |

| |Total Costs Requested For This Project: | |

4. Other Support for PI and Co-investigators in NIH Format

Please provide “other support” information for all investigators

Format

|NAME OF INDIVIDUAL |

|ACTIVE/PENDING |

|Project Number (Principal Investigator) |Dates of Approved/Proposed Project |Person Months |

|Source |Annual Direct Costs |(Cal/Academic/Summer) |

|Title of Project (or Subproject) | | |

|The major goals of this project are… | | |

|OVERLAP (summarized for each individual) |

5. NIH-format biosketches for all key personnel

6. Scientific Plan:

The scientific plan portion of the application cannot be more than 3 pages long, plus one additional page (maximum) of literature citations. The format of the scientific plan should be:

• Specific aims

• Significance and Innovation, including discussion of translational significance

• Research approach, including Preliminary studies (if applicable) and timeline

• Intellectual property considerations (if applicable – required for Ignition Award applications)

• Commercial potential (if applicable – required for Ignition Award applications)

• Plans for future grant submissions or commercial development

• Literature citations

7. Project-specific conflict of interest forms for all investigators

8. Documentation of relevant approvals (or submitted status) by IRB, IACUC, and IBC, as appropriate. Project must be submitted to or approved by appropriate committees at the time of application. Please provide tracking number (e.g. IRB # H-11111, IACUC # AN-11111, or IBC # 11-111). Proposals for which relevant IRB or IACUC applications have not already been submitted will not be accepted.

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