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Request For Pesticide Registry Or Pesticide Application Information - New York State Department Of Health Page 2

Project Director (last name, first initial):_________________________________________________________

II.

PROJECT DESCRIPTION:

Title of Project:

Sponsor(s) of Project (if any):

Releasable Abstract of Proposed Research Project (please attach to this

form, 100 words maximum).

Full Research Proposal or Protocol (please attach to this form). Relevant

information, such as the relationship between the proposed project and the

information sought from the Pesticide Registry or pesticide applicator, may

assist the Board’s evaluation of the researcher’s request for Pesticide

Registry or pesticide application information.

The Research Proposal should also explain how, and why, the proposed

project is human health related research and why the publicly available

aggregate pesticide data are not sufficient for the proposed project.

Biographical Sketch - see attached sheets.

Is the research project to be conducted under the auspices of an institution?

� Yes

� No

If the response to Item E is yes, please provide a copy of the Institutional Review

Board or other equivalent review board approval of such proposal or protocol or,

if such approval has not been obtained, documentation from such IRB or

equivalent review board as to why such approval is not required. If the

Institutional Review Board has approved the research proposal or protocol,

please also provide documentation that the Institutional Review Board has been

approved by the New York State Department of Health and/or the federal

government.

Request For Pesticide Registry Or Pesticide Application Information - New York State Department Of Health Page 2