University of Minnesota Obesity Prevention Center
Internal Review Form (IRF) for Competing Research Proposals
Date:
Please complete all of the following information.
NOTE: Approval form must be submitted to UMOPC at least 2 monthsprior to proposal deadline.
PEER-REVIEW PLAN: Please state how this proposal will be peer-reviewed, and by whom, prior to submission:
1.Principal Investigator: Phone #:
2. eRA Commons User ID:
3.Agency/Sponsor:
• If other than NIH, please list website or attach guidelines to this form:
4.Agency Deadline:
5.If this is a Subcontract, please indicatename and email contactof prime institution:
6.Proposal Title: (Not to exceed 81 typewriter spaces, including spaces between words and punctuation for NIH grants.)
7.Type of Submission: If other than NIH, skip to Q. 8—If this is an NIH application, please check one and
complete the additional information requested.
a. New:
• R01PA#: or Parent R01 (PA-07-070)
•R03PA#: or Parent R03 (PA-06-180)
•R21PA#: or Parent R21 (PA-06-181)
• K07 K08 Other (list here):
b. Revised:Agency # assigned from initial submission:
c. Supplement to existing grant:Agency#: CUFS #:
d. Renewal:Agency#: CUFS #:
8. Dates of Entire Proposed Project Period: Start Date: End Date:
9.Is this a NIH-defined Phase III Clinical Trial? Yes No
(See: - _Toc54600038)
10a.Human Subjects:Does this project involve human subjects?
a. Yes 10b. If YES, what is the status of the Human Subjects Application?
b. No Approval Pending Approved
Exempt: Exemption Category:
Study Code Number:
Approval Date:
11a.Animal Subjects: Does this project involve animal subjects?
a. Yes 11b. If YES, what is the status of the Animal Subjects Application?
b. No Approval Pending Approved
Approval Date:
Study Code Number:
12.List Names of Collaborating Faculty and University Departments:
name/department name/department
13.List Subcontract/Consortium Agreements (if applicable):
a.Institution/PI Name/Phone #:
b.Institution/PI Name/Phone #:
c.Institution/PI Name/Phone #:
14.List Consultants (list full names and affiliation):
15.Use of Fairview Services: Does this project require use of Fairview Services? If so, refer to the following website for necessary procedures to follow for using Fairview services. Complete all necessary forms and requirements.
16. Data Confidentiality: Name the person who will be responsible for data confidentiality and security:
Name: Title: Telephone:
17.Data Collection Services:
17a.Will you need data collection services?
a. Yes
b. NoIf NO, skip to Question18.
17b.If YES, do you plan to use the Health Survey Research Center (HSRC) in the School of Public Health (formerly known as the Data Collection & Support Services (DCSS) in the Div of Epidemiology and Community Health)?
a. YesIf YES, contact Hannah Colon at 5-7896 or Susan Rose at 6-8824.
b. No If NO, skip to Question18.
17c.If YES, check the type of services you will be using:
Abstraction/coding Survey data collection
Forms design/development Telephone
Data entry Internet
Sample selection Mail/paper
Participant recruitment/tracking Other (specify):
18.Space Requirements: For planning and budgeting purposes, please indicate whether sufficient space is currently available for this project:
a. Current space is sufficient.
b. An additional number of cubicles/offices will be needed: Number of cubicles ______
If this space is located at WBOB, please explain:
c. Epidemiology Clinical Research Center (ECRC) space is requested
NOTE: If you are proposing to use the ECRC, you must first email Peg Krieser () prior to submission. If space will not be available at the ECRC and you need off-site clinic space, you will need to include space rental in your proposal budget and this may affect the Facilities and Administration rate used.
19. Mailing Information:If this proposal is being sent as a paper submission to an agency other than the National Institutes of Health, please provide the number of copies required, the name and complete mailing address below:
The original and copies of this application should be sent to:
Name and Address:
20. Study Design: (Check only one)
CohortRandomized Group Trial
Retrospective (Case-Control)Training
DescriptiveIntervention
Randomized Clinical TrialAnalysis
Other (list here)
21.Research/Content Area: (Check up to three)
AlcoholInfectious DiseaseOsteoporosis
CancerMCHPhysical Activity
CVDNutritionSocial Epidemiology
HIV/AIDSObesityTobacco
Other (list here):
22. Abstract/Description of Proposal: (Type below or attach.)
Principal Investigator Signature
Signature Date
I have reviewed the scientific merit of this project and it is within the goals and mission of the University of Minnesota Obesity Prevention Center.
UMOPC Director
Robert W. Jeffery, Ph.D.
Signature Date
Dean,
School of Public Health
John R. Finnegan Jr., Ph.D.Signature Date
cc:Dr. Bernie Harlow
Anne Everett/Char Flipp
Kerrin Brelje
Revised 10/1/2018Page 1 of 4