Pennsylvania Allergy & Asthma Association Research Grant Application

Pennsylvania Allergy & Asthma Association Research Grant Application
For PAERF Use Only - Log No.
Date *

Month Day Year
Date
Applicant's Name *

First Name Last Name
Applicant's Phone Number *
Please enter a valid phone number.
Applicant’s Email *
example@example.com
FIT Enrolled in PA Accredited Training Program?

Yes No
*If Fellow, Complete Training Program Director's Name and e-mail below. Program Director will receive this to sign off on after you complete this form.
Program Director's Name

First Name Last Name
Program Director's Email
example@example.com
Institution Name *
Institution Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Institution Phone *
Institution Fax
Name of Administrative Official to be Notified in the Event of Funding *

First Name Last Name
Administrative Official's Email *
example@example.com
Administrative Official's Phone Number
Please enter a valid phone number.
Administrative Official's Fax
Title of Project *
Total Amount Requested (USD) *
Proposed Start Date *

Month Day Year
Date
Duration *
Approval Information (Check each of the following):

Does this Project Involve the Use of: *

Yes

1a. Human subjects?

2a. Vertebrate animals?

3a. Radioactive materials/radiation-producing equipment?

4a. Investigational new drugs or new devices?

5a. Potentially infectious agents, including human blood or tissue

6a. Carcinogens?

7a. In vitro formation of recombinant DNA?

Approval Attached? (Complete if you selected "yes" in section above)

YES

Protocol File Date

Date Approved

1b.

2b.

If applicable, human subject and/or animal approval are not required at the time of application. However, in the event the grant is funded, applicable approvals must be forwarded to PAERF before any funds are released.
Approval Certifications

The undersigned certify that they are not, to the best of their knowledge, excluded from participation in federally funded activities as a result of government-wide suspension or debarment.

1. FIT APPLICANT: I certify that the above information is accurate and complete as of this date. I agree to accept responsibility for scientific and technical conduct of this project and for provision of required technical reports if a grant or contract is awarded as a result of this application.
Signature FIT APPLICANT *

Clear
Date *

Month Day Year
Date
2. TRAINING PROGRAM DIRECTOR: The attached application is approved. It is within the total program and academic objectives of the Department.

**Program Director will receive this to sign off on after you complete this form.**
Signature Training Program Director's

Clear
Date

Month Day Year
Date
3. If applicable, ADMINISTRATIVE OFFICIAL : The proposed project is approved. It is consistent with the total program objectives of this school and the commitments of this project are acceptable.

**The Administrative Official will receive this to sign off on after you complete this form.**
Signature Administrative Official

Clear
Date

Month Day Year
Date
4. MEMBER APPLICANT: I certify that the above information is accurate and complete as of this date. I agree to accept responsibility for scientific and technical conduct of this project and for provision of required technical reports if a grant or contract is awarded as a result of this application.
Signature Member Applicant *

Clear
Date *

Month Day Year
Date
Application Attachments
To complete your application, for each section below, please attached the requested files. Please note, you will NOT have an opportunity to upload the documents later. :

Section 1: (Application Forms)

1. Research abstract and personnel form

2. Detailed budget page (indirect costs should be included and may not exceed 20% of the direct costs)

3. Resources and environment form

4. Biographical sketch for principal investigator
File Upload *

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Section 2: (Research Plan)

1. Specific aims (one page)

2. Significance (one to two pages)

3. Experimental design and methods (two to three pages)

4. Bibliography (one to two pages)
File Upload *

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Section 3: (Appendix)

1. Institutional Review Board (IRB) and informed consent forms, if human subjects are involved. Studies involving only chart reviews are subject to IRB policy.
2. Institutional Animal Care and Use Committee (IACUC) approval, if laboratory animals are involved.
3. Institutional Biosafety Committee (IBC) form, if biohazardous material is involved (e.g., recombinant DNA).
4. Radiation Safety Committee (RSC) form, if radiation or radioisotopes are involved.
File Upload *

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