Info Grant 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 one Professor Assoc. Professor Asst Professor Other Funding Agency Agency Name Program Name Program # or CFDA # URL for program guidelines or program announcement Budget type: modular detailed Due date: Year -- 2011 2012 2013 2014 2015 2016 2017 2018 2019 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Project Title / temporary title Dates of Project start date Year -- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 end date Year -- 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 / Month -- January February March April May June July August September October November December / Day -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Program Summary (Abstract) Subcontractor 1. Does this proposal involve subcontracts? Yes No 2. If yes, please list subcontractor(s) below: subcontractor 1: subcontractor 2: subcontractor 3: 3. If yes, does the proposed subcontractor's scope of work include the use of animal subjects? Yes No 4. If yes, does the proposed subcontractor's scope of work include the use of human subjects? Yes No Before responding below, for DHHS please check the Letter of Intent AND the Federal Demonstration Partnership (FDP) website to verify that the proposed subcontractor has a compliant conflict of interest policy. For NSF, please check the Letter of Intent to verify that the proposed subcontractor has a conflict of interest policy that complies with Department of Health and Human Services (DHHS) or National Science Foundation (NSF) standards, as applicable to this subaward. 5. If yes, does the proposed subcontractor have a conflict of interest policy that complies with Department of Health and Human Services (DHHS) or National Science Foundation (NSF) standards, as applicable to this subaward? Yes No 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, fill in IRB number. If NO, answer question 4 below. Yes No 3. IRB Application Number 4. * If you have not submitted an application for IRB approval, please check reasons below: JIT Not yet submitted Animal Subjects 1. Does this research involve ANIMAL SUBJECTS? (NOTE: This includes any animal work conducted at UNC-CH, other domestic institutions, and/or foreign institutions. Please take into account any animal work performed at collaborating sites, fee-for-service arrangements, and/or subcontracts.) If NO, proceed to Research Material section below. Yes No 2. If YES, is animal work being conducted at UNC-CH as part of this research? If YES, complete Sections 3-8 below. If NO, skip to Section 7 below. Yes No 3. If YES, has your research team submitted an application for IACUC approval? If YES, complete Sections 4 and 5 below. If NO, skip to Section 6 below. Yes No 4. Enter IACUC Application Number 5. List the Species involved with this project: 6. If no IACUC application, please indicate which of the below applies: JIT Not yet submitted 7. Is animal work being conducted at institutions other than UNC-CH as part of this research? If YES, complete Sections 8-15 below. If NO, skip to Research Materials section below. Yes No 8. Domestic Institutions: Check all that apply. Subcontract = Any external organization that performs grant-supported research activities involving animal subjects under a contract arrangement; Fee-for-service = Any entity conducting animal work for reimbursement; Collaborating Site = Any site conducting animal work that will not be under a subcontract or fee-for-service, i.e. no funds are requested Subcontract Fee-for-service Collaborating Site 9. Foreign Institutions: Check all that apply Subcontract Fee-for-service Collaborating Site 10. Please list all institutions where animal work will be conducted: 11. Please list all animal species to be used in the project: 12. Attach evidence of institution's IACUC approval For animal work to be performed at institutions other than UNC-CH, for each institution please attach evidence of the institution's IACUC approval 13. Attach AAALAC accreditation letter For animal work to be performed at institutions other than UNC-CH, for each institution please attach its most recent AAALAC accreditation letter. 14. Attach evidence of PHS Assurance For animal work to be performed at institutions other than UNC-CH, for each institution please attach evidence of PHS Assurance. 15. If the work involves USDA-covered species, please also provide the institution's USDA Registration Number. Research Materials 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: firstname.lastname@example.org) 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 Judy Culhane Faubert at email@example.com 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 Engagement Community Engagement Community Engagement describes the collaboration between institutions of higher education and their larger communities (local, regional/state, national, global) for the mutually beneficial exchange of knowledge and resources in a context of partnership and reciprocity. The purpose of community engagement is the partnership of college and university knowledge and resources with those of the public and private sectors to enrich scholarship, research, and creative activity; enhance curriculum, teaching and learning; prepare educated, engaged citizens; strengthen democratic values and civic responsibility; address critical societal issues; and contribute to the public good. (Carnegie Foundation for the Advancement of Teaching) Project Activity: Can some or all of the proposed project activity be considered community engagement? Yes No What percentage of the overall project ACTIVITY meets the definition of community engagement? % Please distribute the percentage of community engaged activity by location. Total must equal 100% In North Carolina (%) Outside NC, but within US (%) Internationally (%) Project Budget: Will some or all of the proposed project budget be used for community engagement? Yes No What percentage of the overall project BUDGET meets the definition of community engagement? % Please distribute the percentage of community engaged budget by location. Total must equal 100% In North Carolina (%) Outside NC, but within US (%) Internationally (%) Locations of Budget Expenditures Locations of Budget Expenditures 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 (%): International 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 (%): Locations Relevant to Your Project Many projects are associated with a particular geographic location. For example, for projects involving or affecting human or animal populations (collecting new data or analyzing existing data), these geographic locations would be where the humans or animals live. For environmental studies, these geographic locations would include the site(s) of the phenomenon under study. Please add geographic location(s) relevant to your project below. Ensuring that all pertinent locations are reflected allows UNC-CH to accurately map the areas relevant to this project. In-State County Locations Relevant to Your Project: If the locations relevant to your project are in-state, please select each in-state county location below. Use CTRL+click to select multiple counties. All counties Alamance Alexander Alleghany Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Glasgow Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenoir Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swain Transylvania Tyrrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey Other State Locations Relevant to Your Project: If the locations relevant to your project are in U.S. state(s) other than (or in addition to) North Carolina, please select each state below. Use CTRL+click to select multiple states. All states Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming International Locations Relevant to Your Project If the locations relevant to your project are outside of the U. S., please select each relevant country below. Use CTRL+click to select multiple countries. Afghanistan Albania Algeria American Samoa Andorra Anguilla Antartica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Terr. Brunei Darussalam Bulgaria Berkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Isl Colombia Comoros Congo Congo, The Democratic Republic of Cook Isl Costa Rica Cote D’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Domenica Domenican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Isl. (Malvinas) Fiji Finland France France Metropolitan French Guiana French Polynesia French Southern Terr. Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadaloupe Guam Guatemala Guernsey C.I. Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Isl. Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey C.I. Jordan Kazakhstan Kenya Kiribati Korea, Republic of Korea, Democratic People’s Republic of Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Isl. Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Ireland Northern Mariana Isl. Norway Oman Pakistan Palau Palestinian Authority Panama Panama Canal Zone Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts & Nevis Saint Lucia Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon St. Vincent & Grenadines Sudan Suriname Svalbard and Jan Mayen Isl. Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania United Republic Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks and Caicos Isl. Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Viet Nam Virgin Isl. (British) Virgin Isl. (U.S.) Wales Wallis and Futuna Islands Western Sahara Yemen, Republic of Yugoslavia Zaire Zambia Zimbabwe Additional Notes Notes Please use the space below for additional notes regarding your submission (Ex: Title is not finalized, Submission is tentative, Please verify dates are correct, Please verify that the opportunity is the current one for R01, etc.).