Training
Fellowship
Basic Research
Service
For help in determining Clinical Research or Clinical Trial, use the CT Decision Tool .
Drug
Device
Behavioral
Does this study involve next-generation therapies, as defined below?
Yes No
Definition of Next-Generation Therapies
New
Continuation
Renewal
Resubmission
Supplement
Transfer In
None (e.g., industry-based trials)
Existing Grant/Award Number
Existing Grant/Award Number
* must provide value
Cooperative
Grant
Contract
Subcontract
Pass-Through Entity (if Sub to CHLA)
Due Date
Contact Name
Email
Phone (optional)
Subcontract/award type
* must provide value
Grant
Contract
Pass-Through Entity (if Sub to CHLA)
* must provide value
Pass Through Entity (N/A)
n/a
PTE Due Date
* must provide value
Today M-D-Y
Email
* must provide value
Applicable Research Theme (check all that apply)
* must provide value
Federal
State
Industry/For Profit
Foundation/Not for Profit
International
Local/County
Are you working with Foundation Relations on this application?
* must provide value
Yes
No
Anderson Duque McAllister Outpatient Tower Clinical Trials Unit Saban Research Building Smith Research Tower Maubert Community (various off campus locations) Wilshire Other (specify) n/a
Multiple PD/PI application
If yes, provide the name and institution of each PD/PI, including contact PI, designated by the applicant institution.
* must provide value
Yes
No
Number of co-investigators designated by applicant institution
Co-Investigator (1): Contact PI
Co-Investigator (2): Contact PI
Co-Investigator (3): Contact PI
Co-Investigator (4): Contact PI
Co-Investigator (5): Contact PI
Co-Investigator (6): Contact PI
Co-Investigator (7): Contact PI
Co-Investigator (8): Contact PI
Co-Investigator (9): Contact PI
Co-Investigator (10): Contact PI
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research DBP Research and Donations DBP Training Graduate Medical Education Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
DBP Research and Donations
DBP Training
Graduate Medical Education
Academic Affairs
Academic Affairs
Anesthesiology Critical Care Medicine (ACCM) Intensive Care Unit
Anesthesiology Critical Care Medicine (ACCM) Intensive Care Unit
Nursing Administration Patient and Family Services
Nursing Administration Patient and Family Services
Hospital Operations
Hospital Operations
Anatomic Pathology Clinical Pathology Laboratory Medicine Neuropathology
Anatomic Pathology Clinical Pathology Laboratory Medicine Neuropathology
Adolescent Medicine Bone Marrow Transplant Cardiology Clinical Immunology and Allergy Clinical Translational Science Community Health Services Cystic Fibrosis Dermatology Developmental Disabilities (UCEDD) Emergency Medicine Endocrinology Gastroenterology & Nutrition General Pediatrics Hematology-Oncology Hospital Medicine Infectious Diseases Medical Genetics Neonatology Nephrology Neurology Pediatrics Administration Physical Medicine/Rehabilitation (Rehab) Psychiatry Pulmonology Rheumatology
Adolescent Medicine Bone Marrow Transplant Cardiology Clinical Immunology and Allergy Clinical Translational Science Cystic Fibrosis Dermatology Developmental Behavioral Pediatrics Developmental Disabilities (UCEDD) Emergency Medicine Endocrinology Gastroenterology & Nutrition General Pediatrics Hematology-Oncology Hospital Medicine Infectious Diseases Medical Genetics Neonatology Nephrology Neurology Pediatrics Administration Physical Medicine/Rehabilitation (Rehab) Psychiatry Pulmonology Research on Childrens, Youth & Families Rheumatology
Radiology
Radiology
Director of Research Research Operations
Research Operations
Special Funds Accounting
Cardiothoracic Surgery Dentistry Neurosurgery Ophthalmology Orthopedics Otolaryngology Pediatric Surgery Plastic Surgery Surgery Research Urology
Cardiothoracic Surgery Dentistry Neurosurgery Ophthalmology Orthopedics Otolaryngology Pediatric Surgery Plastic Surgery Surgery Research Urology
Division Number (for PeopleSoft)
View equation
Form Preparer Principal Investigator Pre-Award Analyst Division Admin Division Chief Other (specify)
Last Name
* must provide value
Email Address
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research DBP Research and Donations DBP Training Graduate Medical Education Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
DBP Research and Donations
DBP Training
Graduate Medical Education
Academic Affairs
Academic Affairs
Anesthesiology Critical Care Medicine (ACCM) Intensive Care Unit
Anesthesiology Critical Care Medicine (ACCM) Intensive Care Unit
Nursing Administration Patient and Family Services
Nursing Administration Patient and Family Services
Hospital Operations
Hospital Operations
Anatomic Pathology Clinical Pathology Laboratory Medicine Neuropathology
Anatomic Pathology Clinical Pathology Laboratory Medicine Neuropathology
Adolescent Medicine Bone Marrow Transplant Cardiology Clinical Immunology and Allergy Clinical Translational Science Community Health Services Cystic Fibrosis Dermatology Developmental Disabilities (UCEDD) Emergency Medicine Endocrinology Gastroenterology & Nutrition General Pediatrics Hematology-Oncology Hospital Medicine Infectious Diseases Medical Genetics Neonatology Nephrology Neurology Pediatrics Administration Physical Medicine/Rehabilitation (Rehab) Psychiatry Pulmonology Rheumatology
Adolescent Medicine Bone Marrow Transplant Cardiology Clinical Immunology and Allergy Clinical Translational Science Cystic Fibrosis Dermatology Developmental Behavioral Pediatrics Developmental Disabilities (UCEDD) Emergency Medicine Endocrinology Gastroenterology & Nutrition General Pediatrics Hematology-Oncology Hospital Medicine Infectious Diseases Medical Genetics Neonatology Nephrology Neurology Pediatrics Administration Physical Medicine/Rehabilitation (Rehab) Psychiatry Pulmonology Research on Childrens, Youth & Families Rheumatology
Radiology
Radiology
Director of Research Research Operations
Research Operations
Special Funds Accounting
Cardiothoracic Surgery Dentistry Neurosurgery Ophthalmology Orthopedics Otolaryngology Pediatric Surgery Plastic Surgery Surgery Research Urology
Cardiothoracic Surgery Dentistry Neurosurgery Ophthalmology Orthopedics Otolaryngology Pediatric Surgery Plastic Surgery Surgery Research Urology
Division Number (for PeopleSoft)
View equation
Division Pre-Award AnalystNote: This analyst supports with the budget and proposal development
Last Name
* must provide value
Email Address
* must provide value
Email Address
* must provide value
Is Intellectual Property (discoveries with commercial potential) reasonably expected to result from this project?
* must provide value
Yes
No
Is there existing Intellectual Property, developed at or held by CHLA that is being used in this project?
* must provide value
Yes
No
n/a
Protocol Developed By:
* must provide value
PI
Sponsor
Joint
n/a
Funding Agency/Sponsor
* must provide value
Funding Opportunity Number
Funding Opportunity Number
* must provide value
Funding Opportunity Number (N/A)
n/a
M-D-Y
Agency/Sponsor Due Date (N/A)
n/a
Funding Agency Guidelines
Choose format:
* must provide value
Link/URL
File Upload (PDF)
No guidelines/solicitation/announcement
Link/URL to guidelines
* must provide value
Yes
No
Yes
No
Yes
No
Number of subrecipients
* must provide value
Please submit the below items with your application for team review:
1) SOWInclude additional pages for each recipient if needed.
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
Estimated project amount (all years)
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
Estimated project amount (all years)
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
Estimated project amount (all years)
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
Estimated project amount (all years)
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
Estimated project amount (all years)
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
Estimated project amount (all years)
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
Estimated project amount (all years)
* must provide value
Contact
Est. Project Amount (all years)
$
Contact Email
* must provide value
Estimated project amount (all years)
* must provide value
Is this project non-monetary?
* must provide value
Yes
No
Does the budget cover all costs associated with this project?
* must provide value
Yes No
71% Federal or Non-Clinical/Lab
35% Non-Federal or Industry Sponsored
35% Off Campus
40% Other Sponsor Activity
Sponsor Stated Rate
No IDC allowed
Sponsor State Rate
* must provide value
IDC Recovery (Choices 6, 7, 8)
Modified Total Direct Cost
Total Direct Cost
Salary & Wages
Does this project involve Clinical or Non-Clinical research?
* must provide value
Clinical , fixed-fee1
Clinical , cost-reimbursable2
Non-Clinical
1 In a "fixed fee" contract, the PI agrees to accomplish certain objectives within a specific timeframe for a set dollar amount per patient, per hour, or other unit. These types of contracts are often clinical trials or surveys.2 Cost reimbursement is when funds are expensed on a grant and receives payment after expenditures are made.
Budget for Non-Clinical OR Cost-Reimbursable Clinical Research Project Please estimate the budget dates and costs (in USD) below. Monetary values should include the number only rounded to two decimal places (e.g., 1500.00).
Initial Budget Period Start Date
End Date
Direct Cost Indirect Cost Total Cost Overall Project Period Start Date
End Date
Direct Cost Indirect Cost Total Cost
Estimated Start Date (Initial Budget Period)
* must provide value
M-D-Y
Estimated Start Date (Initial Budget Period) (N/A)
n/a
Estimated End Date (Initial Budget Period)
* must provide value
M-D-Y
Estimated End Date (Initial Budget Period) (N/A)
n/a
Estimated Direct Cost (Initial Budget Period)
* must provide value
Estimated Indirect Cost (Initial Budget Period)
* must provide value
Estimated Total Cost (Initial)
View equation Estimated Start Date (Overall Budget Period)
* must provide value
M-D-Y
Estimated Start Date (Overall Budget Period) (N/A)
n/a
Estimated End Date (Overall Budget Period)
* must provide value
M-D-Y
Estimated End Date (Overall Budget Period) (N/A)
n/a
Estimated Direct Cost (Overall Budget Period)
* must provide value
Estimated Indirect Cost (Overall Budget Period)
* must provide value
Estimated Total Cost (Overall)
* must provide value
View equation Budget for Fixed-Fee Clinical Research Project
Please estimate the budget dates and costs (in USD) below. Monetary values should include the number only rounded to two decimal places (e.g., 1500.00).
Project Start Date
Project End Date
Number of Anticipated Participants Division Start-Up Cost Sponsor Advance Total Costs Based on Anticipated Enrollment Consortium?
Project Start Date
* must provide value
M-D-Y
n/a
Project End Date
* must provide value
M-D-Y
n/a
Number of Anticipated Participants
* must provide value
Estimated Division Start-Up Cost
* must provide value
Estimated Total Costs Based on Anticipated Enrollment
* must provide value
Consortium?
* must provide value
Yes
No
Consortium Organization
* must provide value
Does this project include a foreign collaborator?
* must provide value
Yes
No
I confirm I have submitted a completed Export Control Questionnaire to the Research Compliance office, as required by CHLA Policy COMP 039.0 - Export Control
* must provide value
YES , I have submitted the required forms
NO , I have not yet submitted the required forms
Does the PI participate in any foreign talents programs?
* must provide value
Yes
No
Explain program participation
* must provide value
Does the PI or any individual responsible for the design, conduct, or reporting of the research (as determined by the PI) have any potential conflict of interest (COI) as defined in CHLA's COMP - 021.0 Conflicts of Interest in Research policy (e.g., ownership interest, consulting activity, or management role in the sponsor, sub awardee, or licensee) related to this project?
* must provide value
Yes
No
Total Number of Conflicts of Interest
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
Department
* must provide value
Academic Affairs Anesthesiology Critical Care Medicine (ACCM) CS Education and Research Hospital Operations Pathology Pediatrics Radiology Research Operations Special Funds Accounting Surgery
Faculty
* must provide value
Faculty
Not faculty
Complete
Incomplete
______ : Certification
* must provide value
When marking "approved" for questions 1-7:
You must provide approval documentation with this intake packet If item is "pending" please provide the approval documentation when available to TSRIPreaward@chla.usc.edu 1. Are human subjects (material or data from human subjects) involved?
* must provide value
IRB Approved
Pending
n/a
If approved, please enter IRB Number (use commas to separate multiple entries)
IRB Number
* must provide value
2. Commercially-Available Cell-Line
* must provide value
Yes
No
If yes, no IRB approval needed
a) Is CHLA receiving or providing the data? b) Nature of the Data Set c) Use of Human Induced Pluripotent Stem Cells, Human Totipotent Stem Cells, Human Gametes or Human embryos? d) Use of Human Adult Stem Cells? (needed for state reporting) e) Use of Human Embryonic Stem Cells?
a) Is CHLA receiving or providing the data?
* must provide value
Receiving
Providing
Both
n/a
b) Nature of the Data Set
* must provide value
De-identified Data
Limited Data Set
PHI
n/a
c) Use of Human Induced Pluripotent Stem Cells, Human Totipotent Stem Cells, Human Gametes or Human embryos?
* must provide value
Approved
Pending
n/a
d) Use of Human Adult Stem Cells? (needed for state reporting)
* must provide value
Approved
Pending
n/a
e) Use of Human Embryonic Stem Cells?
* must provide value
Approved
Pending
n/a
3. Use of Vertebrate Animals?
* must provide value
Approved
Pending
n/a
If approved, please enter IACUC number.
IACUC Number
* must provide value
4. Use of biological agenda, infectious agents, recombinant or synthetic nucleic acid molecules? (IBC)
* must provide value
Approved
Pending
n/a
5. Use of radioactive materials or radiation devices?
* must provide value
Approved
Pending
n/a
6. Use of designated acutely toxic or physically dangerous chemicals?
* must provide value
Approved
Pending
n/a
7. Use of carbon or silica-based nanochemistry (particles sized from 1-100 nm)?
* must provide value
Approved
Pending
n/a
Should this proposal result in a successful award, may Research Operations include it in an internal CHLA resource archive, available to other investigators who are applying for similar awards?
If not comfortable sharing the entire application, select "Yes, a portion" and someone from the Research Operations team will work with you on including the portions you are comfortable sharing.
* must provide value
Yes, entire
Yes, a portion
No
The option "
If any intramural awards or programs supported the submission of this application, please check all that apply below
* must provide value
Other Intramural Awards or Programs
* must provide value
The option "
Please check any and all Cores that supported the submission of this application
* must provide value
Should this proposal result in a successful award, will current assigned space meet the needs of the award?
* must provide value
Yes, current research space will meet the needs of this award.
For Grants Only: All proposals must be received five business days prior to the agency deadline per Policy FIN - 049.0 .
For any questions about the form, please email TSRIpreaward@chla.usc.edu . The Grants Team will receive a copy of this form upon completion.
Principal Investigator
______ , ______
PI Certification (Show/Hide section)
I certify that the statements made in the above are true, complete and accurate to the best of my knowledge. I agree to accept the obligation to comply with terms and conditions of any potential agreement, to accept responsibility for the scientific and technical conduct of this project, and for the timely provision of all required reports. I also agree to administer the project in accordance with the policies and procedures of CHLA. I will ensure that all project personnel complete the required training programs. Until new project staff members have been trained, I will ensure that their work is closely supervised for compliance with regulations and policies CHLA, and applicable law. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. Signature Date I hereby delegate administrative and financial approval authority to my administrative leadership team for day-to-day financial administration of this grant to designated administrative staff. This includes, but is not limited to:
Grants managers Budget managers Department managers These staff members are tasked with managing the financial aspects of the project under the guidance and oversight of the PI. Despite this delegation, the PI retains ultimate responsibility for compliance with all grant terms and conditions.
Today M-D-Y
Delegation I hereby delegate administrative and financial approval authority to my administrative leadership team for day-to-day financial administration of this grant to designated administrative staff. This includes, but is not limited to:
grants managers budget managers, department managers These staff members are tasked with managing the financial aspects of the project under the guidance and oversight of the PI. Despite this delegation, the PI retains ultimate responsibility for compliance with all grant terms and conditions.
* must provide value
YES , I APPROVE DELEGATION
NO , I WOULD LIKE TO RECEIVE ALL ELECTRONIC WORKFLOW FOR TRANSACTIONS UNDER THE RESULTANT AWARD
Division Chief
______ , ______
Division Chief Certification (Show/Hide section)
Today M-D-Y
Division Admin
______ , ______
Division Admin Certification (Show/Hide section)
Today M-D-Y
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