PI Last Name
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PI First Name
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PI Division
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SOM: Peds: Cardiovascular Biology (736502) SOM: Peds: Neonatology (736504) SOM: Peds: Rheumatology (736506) SOM: Peds: Endocrinology (736508) SOM: Peds: Gastroenterology (736510) SOM: Peds: Neurology (736512) SOM: Peds: Nephrology (736514) SOM: Peds: Children's Heart Center (736516) SOM: Peds: General Pediatrics (736518) SOM: Peds: Infectious Diseases (736520) SOM: Peds: Emergency Medicine (736522) SOM: Peds: Palliative Care (736523) SOM: Peds: Critical Care Medicine (736524) SOM: Peds: Emory LOBP (736526) SOM: Peds: Allergy (736528) SOM: Peds: Apnea (736530) SOM: Peds: Pulmonology (736532) SOM: Peds: Cystic Fibrosis (736534) SOM: Peds: Marcus Autism (736538) SOM: Peds: General Pediatrics - Egleston (736540) SOM: Peds: Solid Tumor (736541) SOM: Peds: Neuro-Oncology (736542) SOM: Peds: Leukemia Lymphoma (736543) SOM: Peds: Bone Marrow (736544) SOM: Peds: Survivor (736545) SOM: Peds: Hemostasis/Thrombosis (736546) SOM: Peds: Sickle Cell (736547) SOM: Peds: Hematology (736548) SOM: Peds: Gene Therapy (736549) SOM: Peds: ENT (736550) Other, not Department of Pediatrics
PI Preferred Email for Correspondence
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PI Preferred Phone Number for Correspondence
* must provide value
Is this a Clinical Trial?
* must provide value
yes
no
maybe
Other Department/Division
* must provide value
Does your study have a mandatory deadline for submission?
* must provide value
Yes
No
Submission Deadline Date
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Today M-D-Y If less than 3 weeks prior to deadline, Department Chair approval required via Liz McCarty. Please obtain ASAP after completing this form.
Type of Funding
* must provide value
FEDERAL
INDUSTRY
FOUNDATION/ASSOCIATION
INTERNAL FUNDING
OTHER
1, FEDERAL (ex: NIH, DoD, CDC, NIDDK, NCI, NHLBI) 2, INDUSTRY (pharmaceutical company, biotech firm, device manufacturer, ex: Pfizer, BMS, Abbvie) 3, FOUNDATION/ASSOCIATION (ex: AHA, COG, ADA, CIBMTR, HoG, ACS) 4, INTERNAL FUNDING (ex: Seed Grant, Pilot Grant) 5, OTHER (ex: federal contracts, state funding)
If sponsor is NIH, please indicate the type of proposal
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Research Grants (R series)
Career Development Awards (K series)
Research Training and Fellowships (T series)
Program Project/Center Grants (P series)
Research Project Cooperative Agreement (U series)
Not Applicable
Is this this Investigator Initiated?
Yes
No
Are you a new or early investigator?
Yes
No
Name of Other Funding Source
Yes
No
Name of Prime Institution
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Name of PI at Prime Institution
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RFA/RFP Link
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RFA - Request for Application, RFP - Request for Proposal
Action Status
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Original submission
Re-submission
Competitive renewal
Just-in-Time (JIT) Request
Existing (ex: amendment, supplement)
Progress Report/Continuation (RPPR, etc.)
Previous Emory Award ID (if known)
Project Short Title
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Project Full Title (if known)
Today M-D-Y
< 1 1 2 3 4 5 >5
years
Are animals involved at Emory?
* must provide value
Yes
No
Are human subjects involved at Emory or Children's?
* must provide value
Yes
No
Has the IRB submission been started?
* must provide value
Yes
No
What IRB will be utilized?
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Children's IRB Emory IRB WIRB Other
Other IRB
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Please provide the IRB number
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Will you utilize any Children's services, locations, or staff?
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Yes
No
(pharmacy, lab, radiology, Pediatric Research Center (PRC), and/or using Children's staff)
Will you utilize any Emory services?
* must provide value
Yes
No
(pharmacy, lab, radiology, etc.)
Research Performance Location(s)
Emory University (main campus or satellites)
Emory University Hospital (EUH)
Emory University Hospital Midtown (EUHM)
Emory Orthopedic & Spine Hospital
Grady Memorial Hospital
John's Creek Hospital
St. Joseph's Hospital
Emory Clinic (TEC)
Emory Vaccine Center (Hope Clinic)
Grady-Ponce Center
Wesley Woods
Egleston (CHOA)
Scottish Rite (Children's)
Hughes Spalding (Children's)
Marcus Center (Children's)
PRC (Children's)
ACTSI (Emory Hospital, Grady or Midtown)
Emory Children's Center, CSS Clinic (Children's)
Emory Children's Center, ECC-RU (Emory University)
Children's at North Druid Hills (Children's)
Yerkes
VA
Sibley Heart Center (Children's)
Other
Unknown at this time
Investigational Drug Services (IDS) Location(s)
Children's IDS
Emory IDS
Other
Not Applicable
Unknown at this time
Other IDS Location
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Research and/or Local Lab Location(s)
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CAPS Researching Processing Lab (Children's)
HSRB Lab
Emory Medical Lab
Scottish Rite (Children's)
Egleston (Children's)
North Druid Hills (Children's)
Other
Unknown at this time
Other research/local lab location
* must provide value
Please list any additional services and their locations (i.e.-Children's Cardiovascular Imaging Research Core)
Primary Contact for questions about the study
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PI
Coordinator/Nurse
Other
Will you have a Coordinator/Nurse for this study?
Yes
No
Study Coordinator/Nurse Name
Study Coordinator/Nurse Email
Will your project involve subcontractors?
Yes
No
(other than Children's)
Proposal/Protocol document
FINAL VERSION OF PROTCOL IS REQUIRED. Please confirm - is this a FINAL version of the protocol?
yes
no
Sponsor Contract or Agreement
If separate document from contract/agreement
Do you have any additional comments or attachments?
* must provide value
Yes
No
Person completing form
* must provide value
PI
Coordinator/Nurse
Other Contact
Research Administrator
Name:
* must provide value
M-D-Y
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