Name (First, Middlle, Last)
Briefly describe the background and purpose of the research:
Who will be the subjects in this study and how will they be solicited?
Will the project use DNA or RNA molecules?
This can also include viruses, bacteria, cells or organisms constructed with Recombinant DNA methodology or techniques. (If yes, a Memorandum of Understanding and Agreement must be submitted to the IRB
Will this project involve field release of genetically modified organisms?
Are there any potential health or safety risks to project personnel arising from activities conducted overseas?
(If yes, principal investigator must consult with the IRB)
Will live vertebrate animals be used?
(If yes, please submit an animal protocol form to the Institutional Animal Care Board/Committee in the Research and Extension Department)
Is there any planned or potential use of hazardous agents?
e.g., infectious agents, toxins, mutagens, carcinogens, or explosive chemicals. (If yes, provide the Office of Sponsored Programs with an additional copy of the proposal
Is there any planned or potential use of the following: ionizing radiation device?
e.g., accelerators, x-ray machines; diagnostic, therapy microscope, CHESS; an electron reactor of fusion device.
Is there any planned or potential use of the following:
Non-ionizing radiation device (e.g., laser, infrared, ultraviolet, microwave, radio frequency or ultrasonic.
Please specify type:
Is there any planned or potential use of radioactive materials?
(If yes, you must be a permit holder or authorized under a current permit)
Source of external matching funds, if applicable.
Please identify the resources needed, their estimated costs and explain below your plans to cover these costs.
Are there any conflicts of interest?
Do either you or other key personnel on this project have any financial interests in or managerial responsibilities with the proposed project that could create a conflict of interest?
Has any key personnel completed the Animal Disclosure Statement of External Interests and Time Commitments?
Will this project involve faculty leave or release teaching time?
Will this project involve waiver of any indirect costs?