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Grant Proposal Questionnaire
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PI Name
Your answer
Proposal Name
Your answer
Proposal Short Name
Your answer
Proposal Type
Grant
Subaward
Clear selection
If subaward, name of institution
Your answer
Primary Sponsor
Your answer
Due Date
MM
/
DD
/
YYYY
Project Length
Your answer
Funding Announcement Link
Your answer
Key Personnel
(include name, % of effort, role, and institution if not at Dartmouth)
Your answer
General Costs
(i.e.: materials & supplies, animals, etc.)
Your answer
Will there be human subjects?
Yes
No
Clear selection
Does the proposed research involve human specimens and/or data?
Yes
No
Clear selection
Is this a multi-site study that will use the same protocol to conduct non-exempt human subjects research at more than one domestic site?
Yes
No
Clear selection
Are laboratory animals involved in this project?
Yes
No
Clear selection
If
yes
, is the vertebrate animal research being conducted at Dartmouth?
Yes
No
Clear selection
IACUC review status of research:
Approved
Pending
Clear selection
If approved, enter IACUC approval date:
MM
/
DD
/
YYYY
Are human embryonic stem cells involved in this project?
Yes
No
Clear selection
If
yes
, enter embryonic stem cell lines:
Your answer
Biological Safety/Recombinant DNA:
Yes
No
Clear selection
If
yes
, check all that apply:
Recombinant DNA
Human blood, body fluids, cell lines, unfixed tissues
Human pathogens (BSL2 or above)
Does the proposal involve "Select Agents"?
Yes
No
Clear selection
Chemical safety/hazardous materials:
Yes
No
Clear selection
If
yes
, check all that apply
Chemicals classified as "extremely toxic" or "super toxic" (LD50 < 5mg/kg by an route of entry)
Extremely toxic or corrosive compressed gas (LC50 <= 5000 ppm or inhalation hazards)
Explosive, temperature or shock-sensitive materials
Other unstable materials that may undergo chemical or physical changes during use or extreme processes involving high heat, pressure, vacuum or temperature
Carcinogenic chemicals listed or defined by the National Toxicity Program or the International Agency for Research on Cancer
Mutagenic or teratogenic chemicals either known or suspected
"Select Agent" toxins
Radiation (ionizing and non-ionizing) and Imaging Equipment (MRI, NMR, etc...)?
Yes
No
Clear selection
If
yes
, check all equipment that apply:
Ionizing radiation
Non-ionizing radiation
Class IIIb or IV lasers
Imaging equipment (MRA, NMR, etc.)
Other Relevant Information
Your answer
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