<p> 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</p><p>A. SPONSOR/FUNDING SOURCE</p><p>1. GOVERNMENT/FOUNDATION</p><p>Government agency/foundation name: Grant/contract (direct award to Rutgers University) Subcontract (from another institution to Rutgers University). Name of other institution: </p><p>Other: </p><p>Title of proposal: </p><p>Principal Investigator: </p><p>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. </p><p>2. CORPORATE/INDUSTRY Company name: </p><p>Company contact (name, telephone): </p><p>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</p><p>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</p><p>Funding source(s): </p><p>Project/Grant number(s), if any: , 4. OTHER SOURCES Specify: B. COVERAGE OF STUDY-RELATED COSTS</p><p>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 </p><p> covered: Will sponsor/funding source cover costs of any study-related injury? Yes No N/A </p>