HelenDillerFamilyComprehensiveCancerCenter / Application #:
American Cancer Society / First Reviewer:
Individual Research Award Application / Second Reviewer:
Type in unshaded areas only / Date Received:
1. TITLE OF PROJECT (Do not exceed space provided)
2. PRINCIPAL INVESTIGATOR NAME (Last, First) / 3. DEGREE(s)
4. POSITION TITLE / 5. DEPARTMENT
6. TELEPHONE & FAX / 7. BOX NUMBER
Phone: / Box
Fax:
8. EMAIL ADDRESS
9. DATES OF PROPOSED BUDGET PERIOD
(mm/dd/yy -mm/dd/yy ) / 10. COSTS REQUESTED FOR BUDGET PERIOD
$
11. HUMAN SUBJECTS / 12. VERTEBRATE ANIMALS
Indicate Yes or No: / Indicate Yes or No:
If 'yes', IRB approval date: / If 'yes' IACUC approval date:
If 'yes', Human Subjects Assurance #: / If 'yes' Animal Welfare Assurance #:
13. PRINCIPAL INVESTIGATOR ASSURANCE: I agree to accept responsibility for the scientific conduct of the projects and to provide the required progress and expense reports if a grant is awarded as a result of this application. I also agree to abide by the budgetary and other requirements as described in the instructions provided with the application. / SIGNATURE OF P.I. (named in #2)
(Original signature required) / DATE
14. DEPARTMENT CHAIR ASSURANCE: The P.I. of this project has space assigned as an independent investigator that is adequate to conduct of the research described in this application and has salary support during the entire project period. / SIGNATURE OF DEPARTMENT CHAIR
(Original signature required) / DATE
American Cancer Society - Individual Research Award Application
Proposed Budget
PERSONNEL
INST. / DOLLAR AMOUNT REQUESTED
ROLE ON / Calendar / BASE / SALARY / FRINGE / TOTALS
NAME / PROJECT / Months / SALARY / REQUESTED / BENEFITS
0
0
0
0
0
0
PERSONNEL SUBTOTAL / 0
EQUIPMENT
0
SUPPLIES
0
STIPENDS
0
DOMESTIC TRAVEL
0
OTHER EXPENSES
0
TOTAL COSTS / $0

American Cancer Society - Individual Research Award Application

Budget Justification

Provide justification for each item listed on the Budget, page 2

American Cancer Society - Individual Research Award Application

Cancer Relevance Information

The American Cancer Society's donors and volunteers are interested in tracking the expenditures of the Society's research dollars and often additional money is available to support priority areas or research on specific types of cancer. Please check the appropriate boxes that apply to your application.

I. Priority Areas

Choose one or more areas: / % Effort
Prevention (includes Nutrition/Tobacco Control) / %
Detection / %
Treatment / %
Cause/Etiology / %
Total: / 100%

Does your application deal with the Socio-economically Disadvantaged or other Special Populations?

Yes_____No _____

Does your application deal with Psychosocial and Behavioral, Health Policy or Health Services Research?

Yes _____No _____

II. Organ Sites

If applicable, choose one or more sites: / % Effort
Breast
Prostate
Lung
Colon/rectum
Leukemia
Lymphoma
Ovary
Other (please name)
Non Organ Site Specific
Total: (should be 0 to 100%) / %

American Cancer Society - Individual Research Award Application

Cancer Relevance Information (continued)

III. Lay audience summary

Briefly describe, in non-scientific language, how your project relates to cancer in general or specifically to one or more of the above categories. Do not use more than the space provided below.

IV. Scientific audience summary

Briefly describe, in scientific language, how your project relates to cancer in general or specifically to one or more of the above categories. Do not use more than the space provided below.

V. What are your cancer research career goals?

Briefly describe your career goals as they relate to cancer research. Do not use more than the space provided below.

American Cancer Society - Individual Research Award Application

Description of Project

Provide full Description of the Project (as outlined in the instructions). Do not exceed 4 pages of text (not including references).

1

ACS Application