First Name* must provide value
Last Name* must provide value
Degree* must provide value
M.D. Ph.D Other
Degree (Other)
Institution* must provide value
Georgetown University Howard University MedStar Health Research Institute Veteran's Affairs (DC)
School/College* must provide value
Department Name* must provide value
Academic Title* must provide value
Area of Expertise* must provide value
Cellular & Molecular Lab Basic Neuroscience Clinical Medicine and Dentistry Behavioral Science Population Science Health Services Medical Ethics Other
Area of Expertise (Other)* must provide value
Email* must provide value
Phone Number* must provide value
Are you a member of an underrepresented minority group? Yes No
(i.e. American Indian/Alaskan Native, African-American/Black, Mexican-American, and/or Puerto Rican)
Underrepresented Minority Group Native American
African American/Black
Mexican American
Puerto Rican
Does your application have a Co-Principal Investigator?* must provide value
Yes
No
(If your application has more than one Co-PI, please document that in the "Other Comments" section below)
Co-PI First Name* must provide value
Co-PI Last Name* must provide value
Co-PI Degree* must provide value
M.D. Ph.D Other
Co-PI Degree (Other)
Co-PI Institution* must provide value
Georgetown University Howard University MedStar Health Research Institute Veteran's Affairs (DC)
Co-PI School/College* must provide value
Co-PI Department Name* must provide value
Co-PI Academic Title* must provide value
Co-PI Area of Expertise* must provide value
Cellular & Molecular Lab Basic Neuroscience Clinical Medicine and Dentistry Behavioral Science Population Science Health Services Medical Ethics Other
Co-PI Area of Expertise (Other)* must provide value
Co-PI Email* must provide value
Co-PI Phone Number* must provide value
Is the Co-PI a member of an underrepresented minority group? Yes No
(i.e. American Indian/Alaskan Native, African-American/Black, Mexican-American, and/or Puerto Rican)
Underrepresented Minority Group Native American
African American/Black
Mexican American
Puerto Rican
Topic Areas Pilot Project Topic Area
(Please see attachment above for categories and additional information) * must provide value
A B C D1 D2 E
Are you addressing additional topic areas? Yes
No
Additional Pilot Project Topic Area 1* must provide value
N/A A B C D1 D2 E
Additional Pilot Project Topic Area 2* must provide value
N/A A B C D1 D2 E
Additional Pilot Project Topic Area 3* must provide value
N/A A B C D1 D2 E
Project Title* must provide value
Will your project involve more than one site/institution?* must provide value
Yes No
Project Site/Institution* must provide value
Georgetown University Howard University MedStar Health Research Institute Veteran's Affairs (DC) Other
Primary Site/Institution* must provide value
Georgetown University Howard University MedStar Health Research Institute Veteran's Affairs (DC)
Secondary Site/Institution* must provide value
Georgetown University Howard University MedStar Health Research Institute Veteran's Affairs (DC) Other
(if necessary, note tertiary site/location in the "Other Comments" section below)
Other Site/Institution* must provide value
Total Requested Amount* must provide value
( Max. $40,000)
GHUCCTS Resources/Services to be Utilized in Project Biomedical Informatics
Clinical Research Unit(s)
Community Engagement and Research
Design, Biostatistics and Population Studies
Novel Translational Methodologies
Regulatory & Ethics Knowledge & Support
Research Education & Training
Translational Technologies and Resources
(Click All That Apply)
Does your project focus on any of the following underserved populations? Elderly
Minorities
Veterans
Disabled
Other (Please Specify)
Research Doesn't Involve Human Subject Populations
(Click All That Apply)
Other Underserved Population
Other Comments
Number of Georgetown Investigators
Number of Howard Investigators
Number of MedStar Investigators
Number of DCVA Investigators
Number of Investigators at Other Location(s)
Total Number of Investigators
(Please Ensure You are Included in Total Calculation) View equation
Number Automatically Calculated
Have you already obtained regulatory approval for this project?* must provide value
Yes
No regulatory approval at this time
(IRB or IACUC)
IRB/IACUC approval from what institution?* must provide value
GHUCCTS
Georgetown University
Howard University
MedStar Health & Research Institute
Veteran Affairs (DC)
IRB/IACUC Number* must provide value
IRB/IACUC Approval Document * must provide value
CITI Training Certificate
Co-PI CITI Training Certificate
Abstract:
To enable community representative review, we are requiring that abstracts be written to be understood by a lay audience and to not include or clearly define technical terms, and for the abstracts to address relevance to public/community health.
Failure to provide such an abstract could lead to return of the application without it being reviewed.* must provide value
(250-word limit)
Proposal Narrative & Optional Cover Letter* must provide value
(4 Page Max for narrative)
References & Appendixes* must provide value
NIH PHS 398 Budget Form Budget
(Please use NIH Budget PHS 398 template attached above) * must provide value
Budget Justification Template Budget Justification
(Please use the Budget Justification template attached above)
Investigator Biosketch(es)* must provide value
(All Biosketches Need to be Combined into Single PDF File)
Division Chief/Department Chair & GHUCCTS Executive Approval Form
(required to ensure institutional resource support) Department Chair Approval Form Upload &
Optional Letter of Support* must provide value
Submit
Save & Return Later