Form 10-5368 - Department Of Veterans Affairs Research And Development Information System Investigator Data - State Of West Virginia
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1
2DEPARTMENT OF VETERANS AFFAIRS
RESEARCH AND DEVELOPMENT INFORMATION SYSTEM
INVESTIGATOR DATA
581 Huntington, WV
1.
NAME: ___________________________________ 2. DEGREE: ____________________ 3. CID: ______________________
4.
VA TITLE: ______________________________________________________________________________________________
5.
UNIVERSITY APPOINTMENT:
____
________________________________________________
a. Academic Rank
(Enter code from Table 5a)
Code
(Enter name of Academic Rank; if code = 00, skip to Item 5)
____
________________________________________________
b
. University Administrative Title
(Enter code from Table 5b)
Code
(If code = 99, enter name of University Administrative Title)
________________________________________________________
c.
University Department
(Enter name)
________________________________________________________
d
. Department Section/Division
(If application, enter name of Section or Division)
________________________________________________________
e
. University Name
(Enter name of University)
6. D
IPLOMATE STATUS, BOARD CERTIFIED:
Yes
No
NOT APPLICABLE
(See Instructions, Item 6)
7.
____
________________________________________________
PECIALITY:
S
(Enter code from Table 7)
Code
(If code = 99, enter name of Specialty)
8.
____
________________________________________________
SUBSPECIALTY:
(Enter code from Table 8)
Code
(If code = 99, enter name of Subspecialty)
9.
VA EMPLOYMENT:
FULL-TIME
PART-TIME: _____ HR/WK
(Check one)
(If Part-Time, enter hr/wk.)
CONSULTANT
CONTRACT
WOC
10. VA SALARY SOURCE:
VA FUNDS OTHER THAN R&D
MEDICAL RESEARCH (PROGRAM 821) FUNDS
(Check one)
HSR&D (PROGRAM 824) FUNDS
REHAB R&D (PROGRAM 822) FUNDS
COOPERATIVE STUDIES (PROGRAM 825) FUNDS
NOT SALARIED BY VA
11.
____
_________________________________________________
VA HOSPITAL SERVICE:
(Enter code from Table 11)
Code
(If code = 99, enter name of VA Hospital Service)
12.
_________________________________________________________
VA HOSPITAL SECTION:
(If applicable, enter name of Hospital Section)
13. PRIMARY RESEARCH INTEREST:
_____
___________________________________________________________
(Enter code from Table 13-14)
Code
(If code = 99, enter name of Primary Research Interest)
14. SECONDARY RESEARCH INTEREST:
_____
___________________________________________________________
(Enter code from Table 13-14)
Code
(If code = 99, enter name of Secondary Research Interest)
INVESTIGATOR’S SIGNATURE ________________________________________________ DATE ________________________
VA FORM 10-5368
Jan 1997 Modified 12/12/12
PART I – PAGE 18
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