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Providence/Boston CFAR International Research Award Application

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Date: * +

INVESTIGATOR INFORMATION

First Name: *

Last Name: *

Degree: *

Academic Title: *

Institution: *

Department: *

Email: *

Phone Number: *

PROJECT INFORMATION

Project Title: *

Select one: *

New

Resubmission

Type of application *

Initial AIDS Research Project

Pilot Project

Community Engaged Research Project

Name of Mentor *

Mentor Email: *

Does the project take place outside of the US? *

Yes

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: *

Human Subjects

Animal Subjects

Biohazardous Material

Recombinant DNA

None

Other Other

Does this project include a vulnerable population? *

Yes

(See NIH definition for vulnerable populations)

Does this project involve human embryonic stem cells? *

Yes

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:

Clinical & Behavioral Sciences Core

Biostatistical Core

Basic & Translational Sciences Core

Substance Use Research Core

Other Other

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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