Download routing sheet - University of Kansas Medical Center

University of Kansas Medical Center Research Institute
PROPOSAL ROUTING SHEET
DEADLINE:
Date/Time Received______________________________
PROJECT PERIOD: FROM
P.I. INDICATE ONE:
TO
SPA Proposal #_________
Solicitation/Funding Opportunity#
___ 10- business day FINAL
____ 10-business day DRAFT Research Plan/Technical Section
Principal Investigator (Last Name, First Name)
Contact Name/Phone#
___ 5-business day FINAL
E-Mail Address
PI's Department
Administering Dept/Center (F&A Return Dept/Center)
Project Location (Room and Building)
KUMC Centers Related (select as needed)
Select: Select
Select: Select
Select: Select
Select: Select
Project Title:
Major Goals: (Limited to two or three lines):
Funding Agency/Institution (to whom RI submits)
Mechanism (R01, Pilot, etc) Original Source of Funding (if KUMC is subaward)
Please complete Keyword Grid on next page including Community Engagement
Project Type:
Basic Research
T1
T2
Clinical Trial Clinical Research
Training&Educ
Proposal Type:
New
Transfer
Competing Renewal
Revision/Resubmission
Subcontract
Does the proposal include Cost Sharing or Matching Funds?
No
Service
Other (Check all that apply)
Continuation/Supplement to Acct #
Yes (Attach Chairs, Dean’s or Ctr. Director’s Letter of Commitment)
Key Personnel:
Name
Department Name
Project Role
Add additional page for key personnel not listed above
If funded, will project activity require additional space/facilities currently not available to the PI? Yes
(If yes, attach letter to appropriate Dean explaining in detail space/facilities requested)
Are you using Clinical Trial Administration services? Yes
No
Data retention/sharing requirement? YES
NO
If yes, estimated:
gigabyte
terabyte
YES
YES
NO
NO
YES
NO
NO
NO
Cost Share
Effort (if
applicable)
No
DOES THE PROPOSAL INCLUDE ANY OF THE FOLLOWING?
Human Subjects IRB#
Approval Date
Exemption #
Pending
Stem Cells IF YES:
Adult
Umbilical
Somatic Cell Nuclear Transfer
Mouse Embryonic
Other
Human Embryonic : approved cell line number/Source Select or Select / Select__
i.e. WA01/WiCell
Vertebrate Animals IACUC #
Approval Date
Pending
Select Agents (list)
Human Tissues/Body Fluids
Fetal
Placental
Child
Adult
IRB#
or
not Human Subject Determination
YES
NO
Recombinant DNA
YES
NO
Radioisotopes/Radiation Produce Equipment
YES
NO
Biohazards / Hazardous Materials (if yes, attach approval form)
Link to KUMC Office of Compliance
1
YES
YES
Total Effort
Committed
(indicate % or
CYM)
KUMC Safety Forms: EHS Risk Assessment
Please obtain approval from KU EHS Office after award
(see page 3).
SPA Proposal Routing Sheet rev 10-15
KEYWORDS: Please complete this section as it allows the EVC’s office and Enterprise Analytics to track trends.
BODY SYSTEM
Adrenal Glands
Arteries
Bladder
Bones
Brain
Breast
Cardiovascular System
Central Nervous System
Cervix
Colon
Digestive System
Ear
Endocrine System
Esophagus
Eye
Fetus
Gallbladder
Gastrointestinal Tract
Heart
Hypothalamus
Joints
Kidney
Larynx
Ligaments
Liver
Lung
Lymph Node
Muscles
Nerves
Nervous System
Nose
Ovary
Ovum
Pancreas
Penis
Pituitary Gland
Placenta
Prostate
Respiratory System
Skin
Sperm
Spleen
Stomach
Tendons
Testis
Thyroid Gland
Tongue
Uterus
Veins
Urinary Tract
TRAINING
Conference
Junior Faculty
Post Doctorate
Pre-Doctorate
CONDITION
KUMC PROGRAM
Aging
Alcoholism
Alzheimer’s Disease
Autism
Bacterial Infections
Birth/Parturition
Breast Cancer
Cancer
Cardiovascular Disease
Congenital Abnormalities
Congenital Abnormalities
Connective Tissues
Cystic Fibrosis
Diabetes
Disease of Blood
Disease of Digestive System
Disease of Endocrine System
Disease of Ears/Eyes
Disease of Genitourinary System
Disease of Liver
Disease of Lupus
Disease of Muscles/Bones/Connective
Tissue
Disease of Nervous System
Disease of Respiratory System
Disease of Skin
Heart Disease
HIV/AIDS
Infertility/Fertility
Injury/Burns
Kidney Disease
Menopause
Muscular Dystrophy
Mental Disorders
Nutrition
Obesity
Parkinson’s Disease
Pregnancy
Poisons/Toxins
Puberty
Smoking cessation
Stroke
Vascular Disease
Viral Infections
Alternative Medicine and Research
Bioengineering
Bioinformatics
Biostatistics
Bone
Cancer
Clinical and Translational Research
Compound Synthesis
Diabetes
Drug discovery
Heart
High throughput Screening
Integrative Medicine
Immunology/Virology
Kidney
Liver
Mass Spectrometry/Proteomics
Maternal/Fetal/Child Health
Neuroscience/Brain Health
Obesity
Ophthalmology/Ophthalmic
Engineering /Clinical Eye Institute
Personalized Medicine
Public Health
Reproductive Sciences/Fertility
COLLABORATIONS
Across Disciplines
KUMC and another institution
KUMC and Stowers
KUMC and KU-Lawrence
KUMC and St. Luke’s
KUMC and Children’s Mercy
KUMC and UMKC
KUMC and Quintiles
KUMC and pharmaceutical company
KUMC and KCUMB
NEW CENTER
SUBJECT
Animals
Children – boys
Children – girls
Drug
Elderly
Gene
Hormone
Infants
Institution
Men
Pregnant Women
Stem Cells - Adult
Stem Cells – Embryonic
Women
2
COMMUNITY ENGAGEMENT
Community Planning
Local Community Srvc/Research
Other Community Engagement/
Outreach
Rural Health Service/Research
Telehealth/Telemedicine
SPA Proposal Routing Sheet rev 10-15
PROJECT TITLE:
CERTIFICATION/ASSURANCES
PI:
The undersigned certify that neither the PI nor anyone proposed to work on this project are, to the best of their knowledge, excluded from
participation in Federally funded activities as a result of government-wide suspension or debarment.
PI/PROJECT DIRECTOR: I certify that the above information submitted within the application is true, complete and accurate to the best of my
knowledge. I understand that any false, fictitious, or fraudulent statements or claims may subject the PI to criminal, civil, or administrative
penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is
awarded as a result of the application. This project is in compliance with the KUMC Conflict of Interest Policy. If any project personnel has a
potential conflict of interest, financial or otherwise regarding the sponsor of this project, a Conflict of Interest Disclosure Form should be
submitted to the Research Compliance Office.
I understand that NIH requires principal investigators to submit journal articles that arise from NIH funds to the digital archive PubMed Central.
Co-PI: (typed/written)_______________________________________
_____________________________________________
PI/Project Director’s Signature/Date
_________________________________________________________
Co-PI’s Signature/ Date
For Clinical Trials, do any of the investigators, those responsible for obtaining the informed consent of human subjects or any member of their
immediate family have any financial interest or other relationship with any company or entity that sponsors or supports this clinical trial?
Yes
No PI Initials ______________________
(Please add additional signature page for multiple PI’s/Co-PI’s project)
DEPARTMENT CHAIR(s)/CENTER DIRECTOR The attached application is approved. It is within the total program and academic objectives of
the Department/Institution/Center. Adequate space is available or planned for the conduct of the project. The professional time allocations
described therein are approved.
_______________________________________
Department Chair (typed/written)
______________________________________
Department Chair’s Signature
___________________
Dept. Admin. Initials
______________________________________
Collaborating Dept. Chair (typed/written)
______________________________________
Collaborating Dept. Chair’s Signature
___________________
Dept. Admin. Initials
If application involves a Center/Institution:
_____________________________________
Center/Institute Director (typed/written)
______________________________________
Center/Institute Director’s Signature
DEAN OF SCHOOL (or Designee): The proposed project is approved. It is consistent with the total program objectives of this school and the
commitments for this project.
_______________________________________________
Dean’s Signature
KUMC Research Institute Official Signature
_______________________________________________
Associate Vice Chancellor for Research Administration
OTHER APPROVALS
_______________________ Michael Harmelink, Assoc Vice Chancellor for Info Resources & Chief Info Officer (1014 Eleanor Taylor, Ext 8-4900). Required only
for proposals involving computing, telecommunications, telemedicine, internet development, library or computer-based education/training.
_______________________________ Jon Jackson Senior Vice President, Hospital Executive Office (1215 KU Hospital, Ext 8-1289) required only for proposals
using hospital services, facilities, personnel or training programs. Signatures indicate protocol has been reviewed and does not conflict with hospital philosophy or
policy.
_______________________________ Ram Sharma, PhD ,VAMC, KC Assoc. Chief of Staff for Research. Required if VAMC facilities, patients or personnel are
committed.
_______________________________ Richard Couldry (B400 KU Hospital, Ext 8-2330). Required for drug protocols involving investigational Drugs
_______________________________ Ryan Werth or Karen Blackwell, KUMC Office of Compliance (1040 Wescoe Pavillion).
___________________________ Ryan Lickteig or Sonny Cherrito, KUMC Environment, Health and Safety Office (G032 Wescoe)
Helpful links:
NIH Salary Cap, Information Often Requested on Applications, KUMCRI Policies and Procedures, eRA Commons/Grants.gov
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SPA Proposal Routing Sheet rev 10-15