Principal Investigator:

______

Pediatric Mini-Grant Application

Project Title:
Date of Application:
Principal Investigator:
Degree:
Position:
Address:
Phone Number:
Fax:
Email:
Department:
Division:
Applicant Category: /  Faculty
 Resident or Fellow in Pediatrics,  Medicine-Pediatrics,  Other
(list Department and Division) ______
My project Mentor is ______
Anticipated date of training completion: ______
 Mentor letter of support attached
 Medical student at UNMC
Date of matriculation: ______
Anticipated date of graduation: ______
My project Mentor is ______
Note: Project must be completed by the time of graduation
 Mentor letter of support attached
IRB Approval: / Protocol #: Approval Date: ______or Pending?_____
Project is exempt from IRB approval? ______
IACUC Approval: / Protocol #: Approval Date: ______or Pending?_____
Project is exempt from IACUC approval? ______
Endorsing Chair of Applicant’s Division: / Name:
Note: Electronic submission implies approval of Division Chair
Total Funds Requested:
(maximum $5,000)
Dates of Proposed Project Period:
Site of Project:
Principal Investigator
Signature: / Signature: Electronic submission implies signature of applicant.

Project Type (check one)

 Case report

 Case series

 Retrospective chart review

 Prospective exploratory study

 Prospective interventional investigation (drug, device, procedural change, etc.)

 Laboratory-based project

 Other (please describe) ______

Project Abstract *

Project Title:
Abstract: / Objective:
Methods:
Relevance to pediatrics:
Please do not exceed this 1 page length. Project Budget

List cost estimates for research supplies, contract services, clinical tests, patient travel, laboratory technician costs, statistical analysis, research software, small equipment, publication costs, etc. Costs that are not allowed include administrative or secretarial support, clinical consultant fees, and investigator salary and travel. Student salary stipend for research support is allowed.

Project Title:
Detailed Project Budget / From: / Through:
Personnel: / Dollar amount requested:
Name / Title/Position / % Effort / Salary / Fringe Benefits / Totals
Principal Investigator / Not allowed / Not allowed / 0
Subtotals:
Supplies (please itemize):
Other:
Total Request: / $
Budget Justification
Provide justification for major budgetary items in each of the project budget categories (Personnel, Supplies, Other).
Personnel:
Supplies:
Other:
Are matching funds available to support this research? If so, include source and amount:
Biographical Sketch

Investigator:

Project Title:
Name / Position / Title

Education/Training (begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training).

Institution and Location / Degree / Year(s) / Field of Study

Positions: List in chronological order, concluding with present position.

Relevant, recent publications (in chronological order; limit to 15 maximum):

Research Plan

Do not exceed 3 pages, exclusive of references.

1. Hypothesis

2. Specific Aims

3. Background/Preliminary Data

4. Experimental Design/Methods

5. Statistical Analysis

6. Potential Pitfalls/Alternatives

7. Significance to Pediatrics

8. References

1