Collaboration in Translational Research (Ctr)

COLLABORATION IN TRANSLATIONAL RESEARCH (CTR) PILOT GRANT PROGRAM APPLICATION

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PRINCIPAL INVESTIGATOR: RANK / TITLE: DEPARTMENT and SCHOOL: INSTITUTION / AFFILIATION: PURDUE IUB IUSM IUPUI UND IU REGIONAL CAMPUS IBRI CAMPUS ADDRESS: EMAIL: eraCOMMONS USERID: ADDRESS WHERE WORK WILL BE PERFORMED: CO-INVESTIGATOR / COLLABORATOR: RANK / TITLE: DEPARTMENT and SCHOOL: INSTITUTION / AFFILIATION: PURDUE IUB IUSM IUPUI UND IU REGIONAL CAMPUS IBRI CAMPUS ADDRESS: EMAIL: eraCOMMONS USERID: ADDRESS WHERE WORK WILL BE PERFORMED:

TITLE OF PROPOSAL:

RESUBMISSION: YES* NO *If yes, please address or respond to the comments from the reviewers and submit it with the copy of the reviewer’s comments in the submission as supplemental information. TOTAL BUDGET PERIOD: (May not exceed 24 months) From: (Month/Day/Year) To: (Month/Day/Year)

TOTAL AMOUNT REQUESTED (at each institution): PURDUE: $ IUSM: $ IUB: $ IUPUI: $

IUB: $ UND: $ IU Regional Campus: $

TOTAL (may not exceed $75,000) $

APPROVAL YES NO PROTOCOL # DATE RECOMBINANT DNA?

HUMAN SUBJECTS?

VERTEBRATE ANIMALS? ***Note: If you have approvals, please be sure to complete the information above.

REQUIRED APPLICANT AND INSTITUTIONAL SIGNATURES:

Revised September 2017 “The undersigned applicant agrees to accept responsibility for the scientific and technical conduct of the research project and for provision of required progress reports if a grant is awarded as the result of this application. I understand that the second phase of the funding is contingent on successful completion of first phase milestones in all institutions unless specific request for exception is made and approved.”

(If additional investigators from a single institution are involved, please insert a duplicate signature block for applicable investigator, department and/or school signatures.)

SIGNATURES MUST BE OBTAINED FOR EACH PI / CO-PI AND THEIR REPRESENTATIVE INSTITUTIONS

IUSM Signature and Date Applicant Department Head / Chair (1) (1) Departments of Medicine and Pediatric: Division Chief Signature is allowable in lieu of the Department Chair. Institutional Official Signature is not required for IUSM.

IBRI Signature and Date Applicant Chief of Staff/ Executive Vice President

IUB, IUPUI, IU Regional Campus Signature and Date Applicant Department Head / Chair School Dean

Purdue University Signature and Date Applicant Department Head / Chair Institutional Official (1) (1) Signature approval by Pre-Award Center Manager is required by Purdue University.

University of Notre Dame Signature and Date Applicant Department Head / Chair Indicate intent to submit to Melanie DeFord via email ([email protected]). A copy of the completed application, with signatures, must also be sent to Richard Hilliard ([email protected]) by the due date; this is in addition to being uploaded as specified in the ‘CTR Guidelines’. Institutional routing is not required. Contact Richard Hilliard or Melanie DeFord with questions.

Revised September 2017 Abstract This should be a brief (300 word maximum) abstract in layman’s terms. If an award is made, this will be published on the CTSI HUB.

Revised September 2017 Principal Investigator/Program Director (Last, first, middle): DETAILED BUDGET FOR PROJECT PERIOD FROM THROUGH (may not exceed 24-months) DIRECT COSTS ONLY PERSONNEL % DOLLAR AMOUNT REQUESTED (Applicant organization only) (omit cents) ROLE ON TYPE EFFORT INST. SALARY FRINGE NAME PROJECT APPT. ON BASE REQUESTED BENEFITS TOTAL (months) PROJ. SALAR Y Principal Investigator Collaborator

SUBTOTALS CONSULTANT COSTS SUPPLIES TRAVEL PATIENT CARE COSTS OTHER EXPENSES TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD

BUDGET JUSTIFICATION (½ pages): Note - this page may be copied and a separate budget included for each participating site

Revised September 2017 Principal Investigator/Program Director (Last, first, middle):

RESEARCH PLAN (Not to exceed 5-single spaced pages excluding references. Please follow RFA guidelines):

Revised September 2017 OMB No. 0925-0001 and 0925-0002 (Rev. 09/17 Approved Through 03/31/2020)

BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors. Follow this format for each person. DO NOT EXCEED FIVE PAGES. NAME: eRA COMMONS USER NAME (credential, e.g., agency login): POSITION TITLE: EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable. Add/delete rows as necessary.) DEGREE Completion (if Date FIELD OF STUDY INSTITUTION AND LOCATION applicable) MM/YYYY

A. Personal Statement

B. Positions and Honors

C. Contributions to Science

D. Additional Information: Research Support and/or Scholastic Performance

Revised September 2017 Principal Investigator/Program Director (Last, first, middle): C. OTHER SUPPORT: Provide active support for the Principal Investigator. Other Support includes all financial resources, whether Federal, non-Federal, commercial or institutional, available in direct support of an individual's research endeavors, including but not limited to research grants, cooperative agreements, contracts, and/or institutional awards. Training awards, prizes, or gifts do not need to be included.

It is critical that the Other Support page be clear and detailed, and includes funding through program projects, centers, joint grants, and other programs as well as the role of the person in each grant and any potential overlap. Both Active and Pending support should be listed.

Include all information noted below for each proposal / award:

NAME OF INDIVIDUAL ACTIVE / PENDING Project Number Dates of Project Person Months Source (Cal / Academic / Summer) Title Annual Direct Cost

Major Goals of Project

Overlap

Please refer to NIH PHS398 application instructions document for information on completing the biographical sketch and other support pages. Actual NIH forms can be used in place of the ones provided

Revised September 2017