Name of Applicant: ______External Deadline:______
RESEARCH APPROVAL FORM
This form should be utilized by NOSM faculty when applying for funds 1) that will be administered by Lakehead University, Laurentian University, or the Northern Ontario School of Medicine, or 2) as a co-investigator on an application submitted by another institution. If you are a co-investigator, indicate the primary academic affiliation and contact information for the principal investigator. This form, plus a copy of the proposal, must be submitted to the Office of the Associate Dean, Research two weeks prior to the external application deadline. You may fax the signed form to the attention of the Associate Dean, Research at (705) 675-4858, followed by the original mailed to: Associate Dean, Research, Northern Ontario School of Medicine, 935 Ramsey Lake Rd, Sudbury ON P3E 2C6.
Applicant Name:Check one: q Principal investigator q Co-investigator / Academic Division of Applicant (e.g. – Human Sciences):
Applicant Contact Information (Address, telephone, fax, e-mail): / Institution where the majority of the research will be conducted:
q NOSM East Campus q NOSM West Campus
q Other:
List co-investigators (and principal investigator if applicant is a co-investigator) and their Affiliated Institution(s), Faculty and Department:
Title of Proposal:
Keywords Describing the Proposal (list up to five):
Funding Agency and Program (If this is for a sub-grant from another institution, indicate the originating source of funds.):
External Deadline: / Percent of applicant’s
time required for this project:
Type of Submission:
q New q Resubmission q Renewal / Copy of Proposal Attached?
q Yes q No
Type of Funding Requested (Check one):
q Contract/Agreement q Grant q Other ______
Is there partner funding involved in this proposal? q Yes q No
If yes, list the partnering sponsors and level of support:
Special Requirements:
1. Has the proposal been reviewed by a colleague? q No q Yes (Reviewer______)
2. Does the project involve: No Yes, Approval Pending (or) Yes, Approved Protocol #
a) Human subjects? q q q ______
b) Human stem cells? q q q ______
c) Animals? q q q ______
d) Biohazards? q q q ______
e) Radioisotopes? q q q ______
3. Will students be involved in the proposed research? q Yes q No
If yes: q Undergraduate q Graduate q Both
4. Is additional space, renovation to existing space or installation of new equipment required? q Yes q No
(If yes, please attach a brief description and indicate what arrangements you have made.)
5. For faculty located on the West Campus, please complete the Lakehead University Use of Facilities form if you plan to utilize the Lakehead University Centre for Analytical Services, University Instrumentation Laboratory, Greenhouse, LU-CARIS, Paleo-DNA Lab, Forest Soils Lab, and/or other departmental laboratories.
Budget Information Start Date:______End Date: ______
Budget Item / Total of All Years / Funds Requested(12 month periods)
Personnel (Include benefits) / Year 1
Graduate student stipend / Year 2
Supplies / Year 3
Equipment / Year 4
Travel / Year 5
Subcontracts / Grand
Total
Other (Please list.*)
Total Direct Costs (TDC) / q CAD
Overhead (_____% on TDC) / q USD
Grand Total
(Including overhead) / q Other
* If you require more room, please continue on the reverse side.
Signatures
The signature of the Applicant indicates acceptance and willingness to carry out the work as described in the proposal and within the established budget of the proposal. All research activity will be undertaken in accordance with the policies and procedures of the Northern Ontario School of Medicine and the host institutions and in accordance with the terms and conditions of the funding agency/organization. The Principal Investigator also accepts responsibility for any over-expenditure on the award.
Signature of Applicant:______Date:______
Signature of the Division Head acknowledges the research activity described and accepts the availability of resources, including space and the proposed time commitment of the applicant to the project.
Signature of Division Head:______Date:______
Signature of the Associate Dean, Research acknowledges the research activity described and accepts the resource and financial commitments entailed by the activity.
Signature of Associate Dean Research:______Date:______
Signature of University President or Delegate:______Date:______
Revised: October 20, 2006 Page 2 of 2