ADMINISTRATIVE APPROVAL REQUEST FORM FOR ...

ADMINISTRATIVE APPROVAL REQUEST FORM FOR
INTERNALLY SUPPORTED or FUNDED RESEARCH PROJECTS
02/2012
Date: Does this project require clinical release time? YES NO
Is this a request for internal funding? YES NO
Is this a new proposal or renewal? New Proposal Renewal
New proposals require abstract, specific aims, budget summary and justification; Renewals require
progress report with publications.
1. Title of Project
2. Personnel
Principal Investigator:
List all other personnel:
FTE requested:
FTE requested:
Indicate dates of Research ethics (CITI and RCR) training for all investigators or personnel
3. Dates of proposed research project period: From To
4. Is this project currently funded? YES NO
If yes, what is the source of funding for this project?
5. Performance Site (specify location):
6. Does project involve human subjects? (IRB approval required for funding.) YES NO
7. Does project involve animal subjects? (IACUC approval required for funding.) YES NO
8. Will this project involve patients in the clinic? YES NO
If yes, you must provide detailed answers to each of the following:
Is clinical treatment provided?
NO
YES
Is clinical treatment charged to the patient or a third party provider?
YES NO
Will patients be recruited and studied outside of clinic or clinic time?
YES NO

Will clinic instrumentation be used?
NO
YES
9. Is there any equipment that you will borrow, or will be given to you, that is not YES
NO
SUNY-­‐O property (if yes, please complete our loan equipment form on website)
10.. Conflict of Interest Disclosure
Are you free of any personal financial/services/goods involvement with the sponsor, product or
company (including self ownership)? YES NO
(If no, please describe in detail the nature of the relationship)
PI Printed Name and Signature:
Date:

Required Materials (as applicable)
For Intramural funding proposals and requests for clinic release time for research (Complete
Below):
New Proposals – 3-­‐5 pages including: Abstract, Specific Aims, Project Design, Budget and
justification (see below).
Renewal – Specific aims for renewal period, progress report, publications and plan for
completion.
Attach letters of support from relevant Service Chiefs and equipment providers if appropriate.
For Extramural funding proposals and requests for clinical release time (Complete Below):
This form, with detailed answers as appropriate.
Summary of extramural funding application – Abstract, Specific Aims, Budget Summary.
Sponsored Program Authorization and Disclosure of Conflict of Interest Form
For Proposals not requesting funding or clinic release time for research (Complete Below):
New Proposals – 3-­‐5 pages including: Abstract, Specific Aims, Project Design, Budget and
justification (see attached).
Renewal – Specific aims for renewal period, progress report with publications and plan for
completion.
Provide letters of support from Primary Supervisor, relevant Service Chief, and equipment
providers if appropriate.
.
IMPORTANT Submit all required materials with signatures to the Associate Dean, Office of Research
Administration.
Applicant, Do Not Write Below This Line ____________________-­‐
_____________________________________________________________
Administrative Approval Electronic or Written Signatures (following proposal review)
1. Primary Supervisor* Print Name No Yes

Signature
Date
2. VP for Clinical Affairs OR VP for Academic Affairs No Yes
Signature
Date
3. Associate Dean for Research: No Yes
Signature
Date
*Notes:
_____________________________________________________________________________________________________________________
___
APPLICATION FOR INTRAMURAL FUNDING
An approximately 3-­‐5 page application including budget information and justification is
required for all proposals for intramural funding.
Abstract: Short description of project – include purpose and expected outcomes.
Specific Aims: List specific project aims.
Background: Give a short description of the significance of the project.
Project Design: How will the project be executed? Include all special needs and plans (with dates) for
completion. Please indicate your detailed plans for applying for external funding and publication
following completion of this study.
Budget

Personnel: List and explain the role on the project for each individual involved in the project. Give
required release time in FTE or number of clinic sessions.
(Personnel) (FTE or # clinic sessions) (Role on Project (details in project des.) Personnel Role on
Project (details in project des.) FTE or # clinic sessions
Direct Costs:
List and justify all requested costs.
Equipment (itemize) -­‐
Supplies (itemize) -­‐
Travel Expenses -­‐
Patient Care Costs -­‐
Consultant Costs -­‐
Other Expenses -­‐
Total Direct Costs Requested:
Other Requests
List and justify all other requests.
Special equipment required -­‐
Examination rooms (give location, duration and time per week needed)