Medical School Pre-Award & Proposal Development Services Intent Form

Medical School

Pre-Award & Proposal Development Services Intent Form

Please complete this survey if you are requesting pre-award support for one of the listed departments, centers, institutes or programs (CIPs).

Provide as much information as possible and a pre-award team member will contact you to discuss proposal details within 2 business days.

Department or Unit*

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Please specify MS Department*

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Please specify Center, Institute, Program (CIP)

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Please indicate other MS Dept or CIP*

You indicated you are from an area outside the Medical School. Please do not complete this form and contact Jamie Dillon, Director of Pre-Award and Proposal Development Services at: jjdillon@umn.edu

Are you the PI or MPI*

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Your first and last name*

Alternate/Assistant contact (if applicable)

Enter first name, last name and email

RPPR details

Please provide the grant title and number

RPPR Major changes

Have there been major changes over the previous year, or to the originally proposed research?

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RPPR Budget

Describe anticipates budget edits in the coming year (e.g. unobligated balance):

RPPR Human subject/Animal components

If there are human subjects and/or animal components involved, are IRB and/or IACUC protocols in place and approved?

RPPR Subs

If there are sub-award sites, have they been set-up?

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Federal Identifier# of the prior submission?

Please attach relevant materials at the end of this form (if applicable).

Funding Source / Agency

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Enter funding source name*

Enter prime/lead institution

NIH institute*

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Notice of Funding Opportunity (NOFO)/RFA*

If no RFA number is available please paste the URL linked to the funding announcement or attach a PDF version in the Additional Documents section found at the bottom of the page

Project title/working title*

If unknown, enter working title name, topic or "TBD."

Sponsor due date is:*

Receipt date (will not change)

Target date (could change)

Expected project start date*

Project Summary/Abstract and/or Major Goals

Does this research include Indigenous populations?*

Yes

Unsure or TBD

Required Form for Indigenous Research

This form is required eight weeks in advance for UMN investigators who are pursuing Indigenous research as defined in the UMN Guidelines for Indigenous Research and Indigenous Research Policy

More information:

Indigenous research resources

Questions, please contact:

Karen R. Diver

Fond du Lac Band of Lake Superior Chippewa

Senior Advisor to the President for Native American Affairs

Email: karend@umn.edu

PI eRA Commons User Name

PI estimated percent effort*

Multiple PIs?*

Yes

Unsure or to be determined

Multiple PI details

Please list MPI names, x500 if UMN and/or Institute names

Co-Investigators?*

Yes

Unsure or to be determined

Are there subcontracts? *

Yes

Unsure or to be determined

Subcontract details

If known, enter institution, site-PI, admin contact

Study staff*

List MPIs, Co-Is, and research team members names, their x500, and estimated effort. Please include as much detail as possible and what is known at this time.

Research Space*

List all building names and room numbers needed for the proposed research. This is included on the funding proposal. Please include as much detail as possible and what is known at this time.

Proposal is for:*

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Clinical Trial

Sponsor Initiated

PI Initiated

Basic

Basic is defined as a systemic study directed toward fuller scientific knowledge or understanding of the subject studied.

Applied

Applied is research conducted to provide a solution to an established problem, issue, or concern.

Development

Development is the systemic use of knowledge and understanding gained from research directed toward producing useful materials, devices, systems, or methods, including the design and development of prototypes and processes.

Human subjects involved in this project?

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IRB protocol has been submitted

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IRB protocol number(s)

Animal subjects involved in this project?

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IACUC protocol has been submitted?

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Biosafety involved in this project?

This includes: Recombinant or synthetic nucleic acid molecules, infectious agents or biologically-derived toxins

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IBC protocol has been submitted

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Add IBC protocol number(s)

Purchase/use of custom antibodies

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Human embryonic stem (hES) cells involved?

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Specific stem cells

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Human embryos involved in this project?

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Human pluripotent stem cells

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Human fetal tissue or cell lines

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Non-Transplantation use of materials

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Therapeutic use of materials

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Radioactive materials/Radiation

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Human blood, bodily fluids, infectious materials

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Blood-borne pathogen training and immunizations

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Chemicals involved in this project?

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Chemical safety training/hazardous waste training

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Foreign Components

Involves one or more of the following activities in a non-US country(ies):

Sponsors, subawardees, collaborators, or other parties
The export or import of tangible research material(s) to or from a non-US country(ies)
University of Minnesota personnel conducting fieldwork

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Foreign Justification Requirement

IMPORTANT: For projects involving activities outside of the United States or partnerships with international collaborators, a Foreign Justification is required as an "other attachment" at submission time.

See NIH Glossary for a definition of a foreign component.
Application Requirements for Projects Involving Activities Outside of the United States or Partnerships with International Collaborators (NOT-OD-25-098).

Please list each non-US collaborating country

Other compliance considerations

To the best of your knowledge, does the relevant request for proposals, broad agency announcement, draft agreement, or other documentation from the non-University party or parties indicate any of the following? (select all that apply, if known):

The participation of non-US persons will be restricted or prohibited

The other party's (or parties') approval will be required prior to the dissemination or publication of project results

The International Traffic in Arms Regulations (ITAR), Export Administration Regulations (EAR), or other export control regulations apply to the material or research in question

The activity might involve Controlled Unclassified Information (CUI) requiring special IT security controls (e.g., NIST Special Publication 800-171)

Conflict of Interest*

Do you, or your co-investigators, or key personnel or a family member have a financial interest OR business interest in a business entity that could benefit from the results of this project? The interest is related to the research when the business entity:

Sponsors the research.
Owns or licenses a product or technology that will be developed or evaluated in the research.
Will receive a subaward or subcontract for this research.

Yes

Do you have a current REPA on file

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COI - Collaborators*

Do you, or your co-investigators, or key personnel have a familial connection OR financial or business interest (of any amount) with any proposed subrecipient or collaborator?

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COI - Additional Comments

Please add any relevant comments related to COI.

Select all that apply:*

These issues are often topics for further discussion as proposals are prepared. Even if you are not sure about their applicability, choosing one or more now is not a negative and could actually prevent your proposal from being delayed at time of submission.

It is likely that patentable information (e.g., new, useful, or improved) will result from the research

This proposal contains third party or University confidential information (clearly identify the private commercial information in the text of the proposal)

This proposal makes use of Fairview Health Services resources

None of the above are applicable to the proposed research

Program income is anticipated on this project*

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Type(s) of program income*

From fees for services performed

From the use or rental of real or personal property

From the sale of commodities or items fabricated under the award

From license fees and royalties on patents and copyrights that may develop from this project

Other

Renewal - Inventions*

If this is a renewal or continuing project, have any inventions been conceived or reduced to practice under prior research on this project or relating to the work contemplated in this proposal?

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Please upload relevant materials including a draft budget (if applicable)

Drag and drop files here or

Additional Comments:

Provide any additional information/comments/notes here. Be sure to highlight unusual terms or conditions that you notice in the NOFO, reason for short turnaround time, etc.

Send me a copy of my responses