Institutional Review Board (Irb) Initial Application

INSTITUTIONAL REVIEW BOARD (IRB) INITIAL APPLICATION SPONSOR/FUNDING INFORMATION FORM (APPENDIX 3) Has the study been funded at the time of this application? Yes No Pending

A. SPONSOR/FUNDING SOURCE

1. GOVERNMENT/FOUNDATION

Government agency/foundation name: Grant/contract (direct award to Rutgers University) Subcontract (from another institution to Rutgers University). Name of other institution:

Other:

Title of proposal:

Principal Investigator:

Sponsor grant number (if known): For DHHS-funded study, except for cooperative group grants, provide a copy and three copies of the entire grant application. Salary information (not % effort) may be redacted.

2. CORPORATE/INDUSTRY Company name:

Company contact (name, telephone):

Sponsor protocol number (if known): Who designed the study and will have regulatory oversight? Investigato r (investigato r-initiated) Sponsor (sponsor-initiated): THIS STUDY MAY NEED WIRB REVIEW – CONTACT YOUR CAMPUS IRB OFFICE

Does the contract or clinical trial agreement specifically mentions ICH GCP Guidelines? Yes No For industry-sponsored research, submit a copy of the contract or clinical trial agreement. 3. INTERNAL/INSTITUTIONAL FUNDING

Funding source(s):

Project/Grant number(s), if any: , 4. OTHER SOURCES Specify: B. COVERAGE OF STUDY-RELATED COSTS

Will sponsor/funding source provide: some study costs (e.g., salary support, tests, etc.)? N/A drugs/devices? N/A all study costs? N/A If sponsor/funding source will not provide all study costs, explain how unfunded study costs will be

covered: Will sponsor/funding source cover costs of any study-related injury? Yes No N/A