Children S Research Institute

Urea Cycle Disorders Consortium Fellowship in Urea Cycle Disorders Application for Training Award

Investigator Name: Phone: Pager:

Institution Faculty? Yes No Length of Association with Institution: Mentor’s Name: Department: Time to be Devoted to Protocol:

Total Funds Requested: Inclusive Dates for Funding:

PROTOCOL TITLE

Program Director/Principal Investigator (Last, First, Middle):

PROJECT SUMMARY (See instructions):

RELEVANCE (See instructions):

PROJECT/PERFORMANCE SITE(S) (if additional space is needed, use Project/Performance Site Format Page) Project/Performance Site Primary Location

Organizational Name: DUNS: Street 1: Street 2: City: County: State: Province: Country: Zip/Postal Code: Project/Performance Site Congressional Districts: Additional Project/Performance Site Location

Organizational Name: DUNS: Street 1: Street 2: City: County: State: Province: Country: Zip/Postal Code: Project/Performance Site Congressional Districts: PHS 398 (Rev. 08/12 Approved Through 8/31/2015) OMB No. 0925-0001 Page2 Form Page 2 Program Director/Principal Investigator (Last, First, Middle):

SENIOR/KEY PERSONNEL. See instructions. Use continuation pages as needed to provide the required information in the format shown below. Start with Program Director(s)/Principal Investigator(s). List all other senior/key personnel in alphabetical order, last name first. Name eRA Commons User Name Organization Role on Project

OTHER SIGNIFICANT CONTRIBUTORS Name Organization Role on Project

Human Embryonic Stem Cells No Yes If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list: http://stemcells.nih.gov/research/registry/eligibilityCriteria.asp. Use continuation pages as needed. If a specific line cannot be referenced at this time, include a statement that one from the Registry will be used. Cell Line

PHS 398 (Rev. 08/12 Approved Through 8/31/2015) OMB No. 0925-0001 Page3 Form Page 2-continued Numberthe followingpages consecutively throughout the application. Do not use suffixes such as 4a, 4b. Urea Cycle Disorders Consortium Fellowship in Urea Cycle Disorders Application for Training Award

Table of Contents

Face Page------1 Abstract------2 Table of Contents------3 Detailed Budget for Initial Budget Period ------4 Budget for Entire Proposed Period of Support------5 Budget Justification------Letter of Intent……………………………………………………………………………………………….. Applicant’s Biosketch (NIH format)------Mentor’s Biosketch (NIH format)------Applicant’s Other Support------Mentor’s Other Support------Mentor’s recommendation

Research Plan (Limit 10 pages)------Specific Aims------Background and Significance------Preliminary Studies------Research Design and Methods------Human Subjects------Vertebrate Animals------Literature Cited------

Appendix Number of publications and manuscripts accepted or submitted for publication (Not to exceed 10) Program Director/Principal Investigator (Last, First, Middle):

DETAILED BUDGET FOR INITIAL BUDGET PERIOD FROM THROUGH DIRECT COSTS ONLY

List PERSONNEL(Applicant organization only) Use Cal, Acad, or Summer to Enter Months Devoted to Project Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits

ROLE ON Cal. Acad. Summer INST.BASE SALARY FRINGE NAME PROJECT Mnths Mnths Mnths SALARY REQUESTED BENEFITS TOTAL PD/PI

SUBTOTALS CONSULTANT COSTS

EQUIPMENT (Itemize)

SUPPLIES (Itemize by category)

TRAVEL

INPATIENT CARE COSTS OUTPATIENT CARE COSTS ALTERATIONS AND RENOVATIONS (Itemize by category)

OTHER EXPENSES (Itemize by category)

CONSORTIUM/CONTRACTUAL COSTS DIRECT COSTS SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD(Item 7a, Face Page) $ CONSORTIUM/CONTRACTUAL COSTS FACILITIES AND ADMINISTRATIVE COSTS TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD $ PHS 398 (Rev. 08/12 Approved Through 8/31/2015) OMB No. 0925-0001 Page Form Page 4 Program Director/Principal Investigator (Last, First, Middle):

BUDGET FOR ENTIRE PROPOSED PROJECT PERIOD DIRECTCOSTSONLY

INITIAL BUDGET 2nd ADDITIONAL 3rd ADDITIONAL 4th ADDITIONAL 5th ADDITIONAL BUDGET CATEGORY PERIOD YEAR OF SUPPORT YEAR OF SUPPORT YEAR OF SUPPORT YEAR OF SUPPORT TOTALS (from Form Page 4) REQUESTED REQUESTED REQUESTED REQUESTED PERSONNEL: Salary and fringe benefits. Applicant organization only.

CONSULTANT COSTS

EQUIPMENT

SUPPLIES

TRAVEL INPATIENT CARE COSTS OUTPATIENT CARE COSTS ALTERATIONSAND RENOVATIONS

OTHEREXPENSES DIRECT CONSORTIUM/ CONTRACTUAL COSTS SUBTOTALDIRECTCOSTS (Sum = Item 8a, Face Page) F&A CONSORTIUM/ CONTRACTUAL COSTS TOTAL DIRECT COSTS

TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD $ JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.

PHS 398 (Rev. 08/12 Approved Through 8/31/2015) OMB No. 0925-0001 Page Form Page 5 BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors in the order listed on Form Page 2. Follow this format for each person. DO NOT EXCEED FOUR PAGES.

NAME POSITION TITLE eRACOMMONS USER NAME (credential, e.g., agency login)

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable.) DEGREE INSTITUTION AND LOCATION MM/YY FIELD OF STUDY (if applicable)

Please refer to the PHS398 application instructions in order to complete sections A, B, C, and D of the Biographical Sketch.

Include other support at end of the biographical sketch.

Investigator (trainee/applicant): ______

Mentor’s Statement

I, ______, have actively participated in Mentor’s Full Name the design of the research protocol submitted by the above referenced investigator.

To the best of my knowledge, I will be available during the course of this project to guide the investigator in order that he/she may achieve the goals outlined in the protocol.

I am aware that by agreeing to be a mentor to this investigator that I commit myself to active participation in, not only the project design, but that I also commit myself to provide post-award guidance to this investigator. Additionally, I will assist him/her in the search for external funding during the research fellowship period.

I will review the progress report which will be due 60 days following the completion of the project and will encourage the investigator to submit reports to the RSC regarding abstracts presented and/or oral presentation made on the appropriate dates

By virtue of my signature, I agree to mentor this investigator to the best of my ability.

______Signature of Mentor Date Signed Principal Investigator Applicant’s Personal Profile Use this page to introduce yourself to the panel of reviewers. Tell them who you are, your position, your past experience, and identify your mentor. Explain if and when you have used the techniques proposed in this application. If you have not used them, explain how you expect to learn them and the impact this learning curve will have on the completion of this research project.

(Insert Research plan here - Do not exceed 10 pages)