Providence/Boston Center for AIDS Research (CFAR) Application for Developmental Research Funds

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Date: * +

INVESTIGATOR INFORMATION

First Name: *

Last Name: *

Degree: *

Academic Title: *

Institution: *

Department: *

Email: *

Phone Number: *

Investigator Category: *

Category 1- A researcher who is or has ever been PI on an R01 equivalent grant in HIV/AIDS

Category 2- A researcher who is or has ever been PI on an R01 equivalent grant, but never in HIV/AIDS

Category 3- NIH "New Investigator," an individual who has received funding as a PI from directly from NIH, but not yet at the R01 equivalent level

Category 4- A researcher who has not yet received funding directly from the NIH as PI or Co-PI on any NIH grant mechanism

The NIH encourages institutions to diversity their student and faculty populations to enhance the participation of individuals from groups who are nationally underrepresented in the biomedical, clinical behavioral and social sciences. To align with these NIH priorities, the Prov/Bos CFAR is required to collect and aggregate demographic information of nvestigators. This information will only be used to understand the current diversity of the investigator base of the overall CFAR program and will allow the NIH to identify gaps and opportunities for future programmatic planning. Only an aggregate CFAR demographic data report will be sent back to the NIH. We will not send individually identifiable data to the NIH.

*This information is NOT used to determine funding decisions.

Definitions for Racial and Ethnic Categories (https://www.census.gov/topics/population/race/about.html)

Do you identify as Hispanic or Latino/a/x? * 🛈

Yes

No

I prefer not to answer

How do you describe your racial identity? * 🛈

Definitions for Sex and Gender (pg. 4, 20, 21, 118 of NASEM report: https://nap.nationalacademies.org/catalog/26424/measuring-sex-gender-identity-and-sexual-orientation)

How do you describe your gender identity? * 🛈

Individuals with Disabilities: defined as those with a physical or mental impairment that substantially limits one or more major life activities, as described in the Americans with Disabilities Act of 1990, as amended. See NSF data at, https://www.nsf.gov/statistics/2017/nsf17310/static/data/tab7-5.pdf.

Do you identify as an individual with a disability? *

Yes

No

I prefer not to answer

Do you identify as an individual from a disadvantaged backgroud? *

Yes

No

I prefer not to answer

Individuals from Disadvantaged Backgrounds: if individual meets two or more of the following criteria: (https://extramural-diversity.nih.gov/diversity-matters/disadvantaged-backgrounds)

1) Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act (Definition: https://nche.ed.gov/mckinney-vento/);

2) Were or currently are in the foster care system, as defined by the Administration for Children and Families (Definition: https://www.acf.hhs.gov/cb/focus-areas/foster-care);

3) Were eligible for the Federal Free and Reduced Lunch Program for two or more years (Definition: https://www.fns.usda.gov/school-meals/income-eligibility-guidelines);

4) Have/had no parents or legal guardians who completed a bachelor’s degree (see https://nces.ed.gov/pubs2018/2018009.pdf);

5) Were or currently are eligible for Federal Pell grants (Definition: https://www2.ed.gov/programs/fpg/eligibility.html);

6) Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child (Definition: https://www.fns.usda.gov/wic/wic-eligibility-requirements).

7) Grew up in one of the following areas: a) a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural Health Grants Eligibility Analyzer (https://data.hrsa.gov/tools/rural-health), or b) a Centers for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage Areas (qualifying zipcodes are included in the file). Only one of the two possibilities in #7 can be used as a criterion for the disadvantaged background definition.

PROJECT INFORMATION

Project Title: *

Select one: *

New

Resubmission

Please upload your response to the previous reviews *

Type of application *

Initial AIDS Research Project

Pilot Project

Collaborative Project

Community Engaged Research Project

Name of Mentor *

Mentor Email: *

Name of Collaborator(s): *

Collaborator Email: *

Is this an international project: *

Yes

No

Federal Wide Assurance (FWA) for Foreign Performance site(s): *

FWA Number

Pending - will be forwarded when obtained

FWA Number *

Please check all that may apply to your project: *

Does this project include a vulnerable population? *

Yes

No

(See NIH definition for vulnerable populations)

Does this project involve human embryonic stem cells? *

Yes

No

If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list: http://stemcells.nih.gov/research/registry/eligibility Criteria.asp (If a specific line cannot be referenced at this time, include a statement that one from the Registry will be used.) *

Please indicate all of the CFAR Cores from which services will be requested: *

Providence/Boston CFAR Core descriptions

Please describe the type of support that will be requested from each CFAR Core: *

Certfication and Authorizations: *

I agree to accept responsibility for the scientific conduct of this project and comply with the procedures of the Providence/Boston CFAR in providing progress reports as requested in the application instructions. I also agree to acknowledge the Providence/Boston CFAR support in publications and presentations, which may result from this project

Principal Investigator Signature: *

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American Indian or Alaska Native	Asian
Native Hawaiian or Other Pacific Islander	Black or African American
White	Multi-Racial
I use a different term	I prefer not to answer

Cisgender woman	Cisgender man
Nonbinary, genderqueer, or not exclusively female of male	Transgender woman
Transgender man	I use a different term
I prefer not to answer