NIH Proposal Questionnaire Complete Form Purpose: Obtain critical pieces of information to facilitate developing a checklist of required items for successful proposal submission. PD/PI Submitting the GrantProposal Due Date to funding AgencyNIH standard due dates MM slash DD slash YYYY Agency solicitation number / RFA numberProposal TitleApplication Type New Resubmission Renewal Continuation If resubmission or renewal, what is the previous cycle grant number:Proposal DescriptorsLive Vertebrate Animals Yes No What is the current IACUC status? Approved Pending Please provide approval date MM slash DD slash YYYY Human subjectsa living individual about whom an investigator conducting research: Obtains information or biospecimens through intervention or interaction with the individual, and uses, studies, or analyzes the information or biospecimens; or Obtains, uses, studies, analyzes, or generates identifiable private information or identifiable biospecimens Definition of Human Subjects Research Yes No What is the current IRB status? Approved Pending Please provide approval date MM slash DD slash YYYY If yes to human subjects, complete the Clinical Trial Questionnaire:Are the participants prospectively assigned to an intervention? Yes No Is the study designed to evaluate the effect of the intervention on the participants? Yes No Is the effect that will be evaluated a health-related biomedical or behavioral outcome? Yes No Does any of the proposed research in the application involve human specimens and/or data? Yes No Will you use only de-identified data or tissue? De-identified is either (a) anonymous or (b) coded with a confidentiality agreement? Yes No Please don’t forget to provide your Research Administrator with the non-human/exempt determination. irb.ufl.eduDoes the proposed project involve human embryonic stem cells Yes No Does the prosed project involve the use of select agents?https://www.selectagents.gov/ Yes No Does the proposed project involve any foreign components? For example, does the proposal include investigators or collaborators outside the U.S.? Are you receiving a letter of support from a foreign individual or institution? Is a foreign collaborator contributing to the design, conduct, or analysis of your project? Will there be the exchange of samples or data with entities outside the U.S.? Is there any international travel planned that exceeds two weeks? Are you purchasing custom services, development, or analysis from a foreign vendor who will contribute intellectually to the project? Yes No If yes, identify the countriesYou may select more than oneAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsDoes the proposed research fall within the scope of, or is it impacted by, current U.S. government policies, regulations, and laws on dual-use research of concern, gain-of-function research, or research involving pathogens with enhanced pandemic potential? Yes No Consortiums: Will this proposal include consortium(s) to another institution? Yes No If yes, please list institution (S0 name and contact PI)Key Personnel: Identify all key personnel, with role, to be included in the proposal:Any information useful to the submission of this proposal?Would you like a copy of this form emailed to you? Yes No If yes, please enter your email below
