PHS 398, Fp4 (Rev. 11/07), Detailed Budget for Initial Budget Period, Form Page 4

RTRN Small Grants Program – Letter of Intent – 2016 1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation)

2. TRANSLATIONAL RESEARCH LEVEL (select one): T1 T2 T3 T4

T1- Translation to Humans T2- Translation to Patients T3- Translation to Practice T4- Translation to Population Health 3. PRINCIPAL INVESTIGATOR (select one) CLINICAL RESEARCHER BASIC SCIENCE RESEARCHER COMMUNITY RESEARCHER

3a. NAME (Last, first, middle) 3b. DEGREE(S) 3c. REGISTERED ON PROFILES No Yes

3d. ACADEMIC RANK (Professor, Associate Professor, Assistant Professor) 3g. MAILING ADDRESS (Street, city, state, zip code)

3e. INSTITUTION

3f. PRIMARY RTRN CLUSTER AFFILIATION

3h. TELEPHONE AND FAX (Area code, number and extension) 3i. E-MAIL ADDRESS: TEL: FAX: 4. PRIMARY COLLABORATOR OR MULTIPLE PRINCIPAL INVESTIGATOR (select one) CLINICAL RESEARCHER BASIC SCIENCE RESEARCHER COMMUNITY RESEARCHER

4a. NAME (Last, first, middle) 4b. DEGREE (S) 4c. REGISTERED ON PROFILES No Yes

4d. ACADEMIC RANK 4g. MAILING ADDRESS (Street, city, state, zip code) (Professor, Associate Professor, Assistant 4e. INSTITUTION

4f. PRIMARY RTRN CLUSTER AFFILIATION

4h. TELEPHONE AND FAX 4i. E-MAIL ADDRESS (Area code, number and TEL: FAX: 5. PRIMARY MENTOR (IF APPLICANT IS ASSISTANT PROFESSOR) (select one) CLINICAL RESEARCHER BASIC SCIENCE RESEARCHER COMMUNITY RESEARCHER

5a. NAME (Last, first, middle) 5b. DEGREE (S) 5c. REGISTERED ON PROFILES No Yes

5d. ACADEMIC RANK 5g. MAILING ADDRESS (Street, city, state, zip code) (Professor, Associate Professor) 5e. INSTITUTION

5f. PRIMARY RTRN CLUSTER AFFILIATION (if RCMI Faculty) 5h. TELEPHONE AND FAX 5i. E-MAIL ADDRESS (Area code, number and TEL: FAX:

6. PROJECT SUMMARY (50 Word Limit) (OBJECTIVE, TRANSLATIONAL ASPECT OF RESEACH and RELEVANCE TO HEALTH DISPARITIES)

Three Key Words: Please submit the completed LOI template electronically to [email protected], with a copy to the DCC ([email protected]). RTRN SGP Letter of Intent Template for 2016-2017 Funding Cycle