Info Grants Processing - Internal Processing Form Questions for the internal processing form (Ramses) Fill this form out, follow instructions, etc. Principal Investigator Name E-Mail Address Phone # Appointment Select oneProfessorAssoc. ProfessorAsst ProfessorOther Funding Agency Agency Name Program Name Program # or CFDA # URL for program guidelines or program announcement Budget type: modular detailed Due date: Year --20112012201320142015201620172018 / Month --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / Day --12345678910111213141516171819202122232425262728293031 Project Title / temporary title Dates of Project start date Year --19992000200120022003200420052006200720082009201020112012201320142015201620172018 / Month --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / Day --12345678910111213141516171819202122232425262728293031 end date Year --19992000200120022003200420052006200720082009201020112012201320142015201620172018 / Month --JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / Day --12345678910111213141516171819202122232425262728293031 Program Summary (Abstract) Human Subjects 1. Does this research involve HUMAN SUBJECTS? If NO, proceed to ANIMAL SUBJECTS section. Yes No 2. If YES, has your research team submitted an application for IRB approval? If YES, complete Sections 3-8 below. If NO, skip to Section 9 below. Yes No 3. IRB Application Number 4. Will existing data, research records, patient records, and/or biological human specimens be involved? Yes No 5. Will surveys, questionnaires, interviews or focus groups with subjects be conducted? Yes No 6. Will investigational drugs or devices be used? Yes No 7. Will there be direct interaction or contact with the subjects? Yes No 8. This project will involve: Check all that apply Healthy Volunteers Patient Populations Prison Populations Minors up to 17 yrs. old Pregnant Females 9. If no IRB application, please indicate which of the below applies: JIT Not yet submitted Animal Subjects 1. Does this research involve ANIMAL SUBJECTS? If NO, proceed to EHS section below. Yes No 2. If YES, has your research team submitted an application for IACUC approval? If YES, complete Sections 3-8 below. If NO, skip to Section 9 below. Yes No 3. Enter IACUC Application Number 4. List Species 5. Will animals be bred as a part of this project? Yes No 6. Will surgical procedures be used? Yes No 7. Will tumors be induced? Yes No 8. Will tissues be collected? Yes No 9. If no IACUC application, please indicate which of the below applies: JIT Not yet submitted Environment, Health and Safety 1. Radioactive material? Yes No 2. Potential biological hazards (viruses, recombinant DNA, etc.)? Yes No 3. Chemical hazards (poisons, explosives, reagents, flammables, carcinogens, etc.)? Yes No 4. Use of botulinum neurotoxins, botulinum neurotoxin producing species of Clostridium, or preparations or pharmaceuticals containing botulinum neurotoxins? Yes No 5. Materials provided by the sponsor or any other party? Yes No If the proposal involves any of the above materials, contact the Department of Environment, Health and Safety (DEHS) for required approvals at 962-5507 (email: dehs@unc.edu) Subcontractor 1. Does this proposal involve subcontracts? Yes No 2. If yes, please list subcontractor(s) below: subcontractor 1: subcontractor 2: subcontractor 3: Export Control Export control web sites have been created to assist with determining whether compliance issues exist. If you have a specific question about export control regulations, please contact Will Tricomi or visit one of the following export control web sites:http://research.unc.edu/osr/policies/export_control.phphttp://www.unc.edu/depts/legal/newlinks.html 1. Have you signed or been asked to sign a DoD Form 2345 "Militarily Critical Technical Data Agreement" related to this project? Yes No 2. Do you anticipate that the project work may involve sending/transporting/transmitting/carrying any material or equipment related to this project outside the US (examples include: GPS, Biologicals, diagnostic kits, reagents)? Yes No 2B. If yes, list materials. 3. Do you anticipate that the project work may involve travel outside the US? Yes No 3B. If yes, list countries. 4. Do you anticipate that the project work may involve transmitting funds (through payments, for example) or goods or technology to any of the following countries on the OFAC list? Balkans, Burma, Cuba, Iran, Iraq, Ivory Coast, Lebanon, Liberia, Libya, North Korea, Rep. of Congo, Sudan, Syria and Zimbabwe Yes No 5. Some types of research may have export control implications even if all work is conducted in the U.S. Do you anticipate that the project work may involve non-commercial encryption or information security software? Yes No 6. Do you anticipate that the project work may involve any equipment, technology, materials or software specifically designed, modified, or adapted (even slightly) for a military purpose that may involve national security? Yes No 7. Do you anticipate that the project work may involve any Classified materials, equipment, technology or data? Yes No Intellectual Property 1. Have you disclosed any of this research to the Office of Technology Development? Yes No If yes, please enter the title(s) If you have not disclosed any of this research, do you think this research has the potential for a patent? Yes No 2. Does the research in this proposal involve any filed patents? Yes No 3. Does the research in this proposal involve any issued patents? Yes No 4. Will this research use any materials obtained from a third party under a transfer agreement granting ownership rights in inventions and/or data out of the use of the material? Yes No 5. Will this research use any material, patented or otherwise, which is owned by UNC-CH and licensed to a commercial entity? Yes No 6. Is this proposal an SBIR (Small Business Innovative Research Program)? Yes No 7. Is this proposal an STTR (Small Business Technology Transfer Program)? Yes No If yes, please answer questions A, B and C below: A) Will you be the designated Principal Investigator for this project? Yes No B) What is your formal relationship with the applicant organization? Board of Directors Company Officer Scientific Review Board Other C) Will at least thirty percent (30%) of the work of the STTR be performed by UNC-CH? Yes No Community Benefits All sponsored programs provide benefits in the sense of institutional support, employment, training of students, and the economic multiplier effect (i.e., university, employee, student, and visitor spending). However, these questions address projects that emphasize benefits to citizens beyond the immediate university community. 1. Does this project promote economic development? Yes No If yes, check all that apply: In North Carolina Outside NC, but within US Internationally 2. Does this project provide information, services or other resources directly to the community? Yes No If yes, check all that apply: In North Carolina Outside NC, but within US Internationally 3. Does this project promote the health and well-being of community residents? Yes No If yes, check all that apply: In North Carolina Outside NC, but within US Internationally 4. Does this project involve the study of birth-to-12th grade education? Yes No If yes, check all that apply: In North Carolina Outside NC, but within US Internationally 5. Does this project promote adult education and/or life-long learning? Yes No If yes, check all that apply: In North Carolina Outside NC, but within US Internationally 6. Does this project involve research with an Institute or Center within UNC-CH? Yes No The UNC Tomorrow report has identified several areas where UNC must report on existing activities that meet the needs of North Carolina. Please interpret these areas broadly and select one from the list below that best describes your PRIMARY activity. If you feel that your activity does not fall within one or more of these choices, please choose “Other”. Global Readiness Increasing Access to Higher Education Improving Public Education Economic Transformation and Community Development Health Environment Other In addition, please check any in below list that may ALSO describe your activity (check all that apply). If you feel that your activity does not fall within one or more of these choices, please choose “Other”. Global Readiness Increasing Access to Higher Education Improving Public Education Economic Transformation and Community Development Health Environment Other Location of Sponsored Activity Please indicate the locations where your research will occur and assign a percentage to each location. Percentages should reflect the portion of the total budget which would expended in that location. UNC-CH Locations: If any sponsored activities occur on campus, please enter below each on-campus location and the percentage of work that will be done there: Location Percent of work (%): Location Percent of work (%): Location Percent of work (%): In-State County Locations: If any sponsored activities occur in-state, please enter below each in-state county location and the percentage of work that will be done there:Note: If activities occur on campus, do not also add Orange County as a separate In-State location. Location Percent of work (%): Location Percent of work (%): Location Percent of work (%): Out-of-State Locations: If any sponsored activities occur in other U.S. States outside North Carolina, please enter below each state and the percentage of work that will be done there: Location Percent of work (%): Location Percent of work (%): Location Percent of work (%): Out-of-Country Locations: If any sponsored activities occur outside of the Unites States, please enter below each location and the percentage of work that will be done there: Location Percent of work (%): Location Percent of work (%): Location Percent of work (%):
