<p> RTRN Small Grants Program – Letter of Intent – 2016 1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation)</p><p>2. TRANSLATIONAL RESEARCH LEVEL (select one): T1 T2 T3 T4 </p><p>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 </p><p>3a. NAME (Last, first, middle) 3b. DEGREE(S) 3c. REGISTERED ON PROFILES No Yes</p><p>3d. ACADEMIC RANK (Professor, Associate Professor, Assistant Professor) 3g. MAILING ADDRESS (Street, city, state, zip code)</p><p>3e. INSTITUTION</p><p>3f. PRIMARY RTRN CLUSTER AFFILIATION</p><p>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 </p><p>4a. NAME (Last, first, middle) 4b. DEGREE (S) 4c. REGISTERED ON PROFILES No Yes</p><p>4d. ACADEMIC RANK 4g. MAILING ADDRESS (Street, city, state, zip code) (Professor, Associate Professor, Assistant 4e. INSTITUTION </p><p>4f. PRIMARY RTRN CLUSTER AFFILIATION</p><p>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 </p><p>5a. NAME (Last, first, middle) 5b. DEGREE (S) 5c. REGISTERED ON PROFILES No Yes</p><p>5d. ACADEMIC RANK 5g. MAILING ADDRESS (Street, city, state, zip code) (Professor, Associate Professor) 5e. INSTITUTION </p><p>5f. PRIMARY RTRN CLUSTER AFFILIATION (if RCMI Faculty) 5h. TELEPHONE AND FAX 5i. E-MAIL ADDRESS (Area code, number and TEL: FAX:</p><p>6. PROJECT SUMMARY (50 Word Limit) (OBJECTIVE, TRANSLATIONAL ASPECT OF RESEACH and RELEVANCE TO HEALTH DISPARITIES) </p><p>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 </p>