THE MAGEE WOMENS RESEARCH INSTITUTE CLINICAL TRAINEE RESEARCH AWARD FACE PAGE (must be typewritten) PROPOSED BUDGET Personnel List effort for all personnel to be involved in carrying out the proposed research, whether or not salary is – requested, beginning with P.I. APPLICANT INFORMATION NAME (Last, first, middle) DEGREE(S): ARE YOU A RESIDENT OR FELLOW: OFFICE MAILING ADDRESS (building, room, street, city, state, POSITION TITLE: zip code) YEAR(S) IN TRAINING: YEAR(S) IN CURRENT PROGRAM: DEPARTMENT TEL: FAX: E-MAIL ADDRESS: APPLICATION TITLE: HUMAN SUBJECTS RESEARCH No Yes IRB APPROVAL DATE: VERTEBRATE ANIMALS No Yes IACUC APPROVAL DATE: FUNDS REQUESTED DEPARTMENT CHAIR OR FACULTY SPONSOR DIRECTOR OF FELLOWSHIP/RESIDENCY PROGRAM Name Name Title Title SIGNATURE SIGNATURE APPLICANT SIGNATURE DATE % Salary Fringe Name Role Effort Requested Benefits* Total $ $ $ Principal Investigator
THE MAGEE WOMENS RESEARCH INSTITUTE CLINICAL TRAINEE RESEARCH AWARD APPLICANT INFORMATION NAME (Last, first, middle) DEGREE(S): ARE YOU A RESIDENT OR FELLOW: POSITION TITLE: OFFICE MAILING ADDRESS (building, room, street, city, state, zip code) YEAR(S) IN TRAINING: YEAR(S) IN CURRENT PROGRAM: DEPARTMENT TEL: FAX: E-MAIL ADDRESS: APPLICATION TITLE: HUMAN SUBJECTS RESEARCH No Yes IRB APPROVAL DATE: VERTEBRATE ANIMALS No Yes IACUC APPROVAL DATE: FUNDS REQUESTED FACULTY SPONSOR DEPARTMENT CHAIR OR DIRECTOR OF FELLOWSHIP/RESIDENCY PROGRAM Name Name Title Title SIGNATURE SIGNATURE APPLICANT SIGNATURE DATE FACE PAGE (must be typewritten) PROPOSED BUDGET Personnel – List effort for all personnel to be involved in carrying out the proposed research, whether or not salary is requested, beginning with P.I. Name Role % Effort Salary Requested Fringe Benefits* Total Principal Investigator $ $ $
CTRA-Application-2015.docx