Tracking Number:
Funding Opportunity Number:
. Received Date:
OMB Number: 4040-0001
Expiration Date: 06/30/2016
RESEARCH & RELATED Other Project Information
1.
Are Human Subjects Involved?*
Y: Yes
Yes
N: No
No
1.a. If YES to Human Subjects
Is the Project Exempt from Federal regulations?
Y: Yes
Yes
N: No
No
If YES, check appropriate exemption number:
✔
1
✔
2
✔
3
✔
4
✔
5
✔
6
If NO, is the IRB review Pending?
Y: Yes
Yes
N: No
No
IRB Approval Date:
Human Subject Assurance Number
2.
Are Vertebrate Animals Used?*
Y: Yes
Yes
N: No
No
2.a. If YES to Vertebrate Animals
Is the IACUC review Pending?
Y: Yes
Yes
N: No
No
IACUC Approval Date:
Animal Welfare Assurance Number
3.
Is proprietary/privileged information included in the application?*
Y: Yes
Yes
N: No
No
4.a. Does this project have an actual or potential impact - positive or negative - on the environment?*
Y: Yes
Yes
N: No
No
4.b. If yes, please explain:
4.c. If this project has an actual or potential impact on the environment, has an exemption been authorized or an environmental assessment (EA) or environmental impact statement (EIS) been performed?
Y: Yes
Yes
N: No
No
4.d. If yes, please explain:
5.
Is the research performance site designated, or eligible to be designated, as a historic place?*
Y: Yes
Yes
N: No
No
5.a. If yes, please explain:
6.
Does this project involve activities outside the United States or partnership with international collaborators?*
Y: Yes
Yes
N: No
No
6.a. If yes, identify countries:
6.b. Optional Explanation:
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7.
Project Summary/Abstract*
8.
Project Narrative*
9.
Bibliography & References Cited
10.
Facilities & Other Resources
11.
Equipment
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