University of Cincinnati PS2 Grant Program Grant Application 1. TITLE OF PROJECT (Do not exceed 56 characters, including spaces and punctuation.) 1a. Type of application: New Application Renewal Application New CCTST Investigator No Yes 2. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR 2a. NAME (Last, first, middle) 2b. DEGREE(S) 2c. POSITION TITLE 2d. MAILING ADDRESS (Street, city, state, zip code) 2e. DIVISION 2f. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT E-MAIL ADDRESS: 2g. TELEPHONE AND FAX (Area code, number and extension) TEL: FAX: 3. PRIMARY MENTOR 3b. DEGREE(S) 3a. NAME (Last, first, middle) 3d. MAILING ADDRESS (Street, city, state, zip code) 3c. POSITION TITLE 3e. DIVISION 3f. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT E-MAIL ADDRESS: 3g. TELEPHONE AND FAX (Area code, number and extension) TEL: FAX: 4. Human Subjects Research 4a. Research Exempt 4b. Human Subjects Assurance No. 5. Human Subjects Protection No Yes No Yes Certification: 4c. NIH-Defined Phase I Clinical Trial No Yes If “Yes,” Exemption No. No Yes 5a. Certification Date: 6. Vertebrate Animals 7. IBC Protocol 8. Radiation No Yes No Yes No Yes 6a. IACUC Approval 7a. Approval Date: If “Yes,” If “Yes,” Date 8a. If “Yes,” Approval 7b. Approval Number: Date 6b. Animal Welfare Assurance No. COSTS REQUESTED 9. DATES OF PROPOSED PERIOD OF Direct Costs ($) SUPPORT (month, day, year—MM/DD/YY) From Through 10/01/16 09/30/17 12. The undersigned reviewed this application for a PS2 research award and are familiar with the policies, terms, and conditions concerning research support and accept the obligation to comply with all such policies, terms, and conditions. Primary Applicant: Division Chair of Primary Applicant: Signature of Primary Applicant Date: Signature of Division Chair of Primary Applicant Date:
University of Cincinnati PS2 Grant Program Grant Application 1. TITLE OF PROJECT (Do not exceed 56 characters, including spaces and punctuation.) 1a. Type of application: New Application Renewal Application 2. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR New CCTST Investigator No Yes 2a. NAME (Last, first, middle) 2b. DEGREE(S) 2c. POSITION TITLE 2d. MAILING ADDRESS (Street, city, state, zip code) 2e. DIVISION 2f. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT 2g. TELEPHONE AND FAX (Area code, number and extension) E-MAIL ADDRESS: TEL: FAX: 3. PRIMARY MENTOR 3a. NAME (Last, first, middle) 3b. DEGREE(S) 3c. POSITION TITLE 3d. MAILING ADDRESS (Street, city, state, zip code) 3e. DIVISION 3f. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT 3g. TELEPHONE AND FAX (Area code, number and extension) E-MAIL ADDRESS: TEL: FAX: 4. Human Subjects Research No Yes 4a. Research Exempt No Yes If “Yes,” Exemption No. 4b. Human Subjects Assurance No. 4c. NIH-Defined Phase I Clinical Trial No Yes 5. Human Subjects Protection Certification: No Yes 5a. Certification Date: 6. Vertebrate Animals No Yes 6a. If “Yes,” IACUC Approval Date 6b. Animal Welfare Assurance No. 7. IBC Protocol No Yes 7a. If “Yes,” Approval Date: 7b. Approval Number: 8. Radiation No Yes 8a. If “Yes,” Approval Date 9. DATES OF PROPOSED PERIOD OF SUPPORT (month, day, year—MM/DD/YY) COSTS REQUESTED Direct Costs ($) From Through 10/01/16 09/30/17 12. The undersigned reviewed this application for a PS2 research award and are familiar with the policies, terms, and conditions concerning research support and accept the obligation to comply with all such policies, terms, and conditions. Primary Applicant: Division Chair of Primary Applicant: Signature of Primary Applicant Date: Signature of Division Chair of Primary Applicant Date:
PS2-Application-0416.docx