Va Form 10-1313-1 - Merit Review Application
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1MERIT REVIEW APPLICATION
1. LAB NO.
2. APPLICATION NO.
3. REVlEW GROUP
4. REVIEW DATE
5. FACILITY NO.
6. LOCATION HEALTH CARE FACILITY (VAMC, OPC, CITY, STATE)
7. SOCIAL SECURITY NO.
8. DATE OF LAST
SUBMISSION -MR
9. PRINCIPAL INVESTIGATOR(S) (Last Name, First Name, M.i. )
DEGREE
TELEPHONE NUMBERS(S)
10. PROGRAM TITLE (72 Characters maximum)
11. AMOUNT REQUESTED EACH YEAR
1ST
2ND
3RD
4TH
5TH
TOTAL
12. VA EMPLOYMENT STATUS
13. VA SALARY SOURCE
FULL TIME
RESEARCH CC 103
PATIENT CARE
PART TIME (
/8 TIME)
RESEARCH CC 104
HSR&D
CONSULTIN ____ HRS./WEEK
RESEARCH CC 105
RR&D
ATTENDING ____HRS./WEEK
RESEARCH CC 110
OTHER VA
WOC ____HRS. WEEK
CAREER DEVELOPMENT CC 108
15. PROGRAM
COST CENTER
16. PRIMARY RESEARCH PROGRAM AREA
PRIMARY RESEARCH SPECIALTY AREA
17. VA HOSPITAL SERVICE AND SECTION
18. ACADEMIC RANK, DEPARTMENT AND AFFILIATION
19. PROGRAM USE (Each Item must have a response)
HUMAN SUBJECTS
YES
NO
INVESTIGATIONAL DRUGS
YES
NO
RADIOISOTOPE
YES
NO
ANIMAL SUBJECTS
YES
NO
INVESTIGATIONAL DEVICES
YES
NO
BIOHAZARDS
YES
NO
20. SUMMARY OF RESEARCH/ DEVELOPMENT SUPPORT FOR THREE PRIOR
TOTAL VA
TOTAL NON-VA
GRAND TOTAL
FY
F
FY
21.DATE ENTERED ON DUTY VA, OR EXPECTED DATE OF ENTRY VA
SIGNATURE PRINCIPAL INVESTIGATOR(S)
Date
SIGNATURE ACOS FOR RESEARCH AND DEVELOPMENT
Date
VA FORM
10-1313-1
Page 1 of VA Form 10-1313 package
DEC 2006
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