Va Form 10-1436 -

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CONTROL NUMBER
RESEARCH AND DEVELOPMENT INFORMATION SYSTEM
(Leave blank)
PROJECT DATA SHEET
2. LOCATION (City, State)
1. HEALTH CARE
3. PRINCIPAL INVESTIGATOR (Last, First, M.I., Degree)
4. SOCIAL SECURITY NO.
FACILITY NO.
5. STATUS IN PROJECT
6. PROJECT NUMBER
7. TYPE OF REPORT
01 AWARDEE (Recipient of Award)
INITIAL
PROGRES
FINAL
02 NOT AWARDEE, BUT RESPONSIBLE VA
INVESTIGATOR
8. PROJECT TlTLE (Do Not Exceed 142 Spaces)
9. HAS PROJECT TITLE CHANGED SINCE LAST REPORT?
YES
NO
10. CO-PRINCIPAL INVESTIGATOR(S) NAME, DEGREE(S) AND SOCIAL SECURITY NO. (Maximum of 2)
_ _ _ _ - _ _ - _ _ _ _ _ _
_ _ _ _ - _ _ - _ _ _ _ _ _
1.
2.
11. FUNDING AND ADMINISTRATION (See codes on instruction sheets)
ADMIN. CODE
FUNDING CODE
NAME IF "OTHER"
1.
2.
3.
12. PROJECT USES (Each item must have a response)
YES
RADIOISOTOPES
HUMAN SUBJECTS
YES
NO
INVESTIGATIONAL
NO
YES
NO
ANIMAL SUBJECTS
YES
NO
YES
NO
NO
INVESTIGATIONAL DEVICES
BIOHAZARDS
YE
13. RESEARCH FOCUS: (Mark yes only if the major reason for the research project is to study the particular topic)
YES
NO
AGENT ORANGE (DIOXIN)
FEMALES
YES
NO
YES
PRISONERS OF WAR
NO
14. KEYWORDS (MeSH terms only; minimum three, specify up to eight)
1.
5.
2.
6.
3.
7.
8.
4.
15. ABSTRACT (Enter on reverse)
16. SIGNATURE OF PRINCIPAL INVESTIGATOR
17. DATE
VA FORM
10-1436
EXISTING STOCKS OF VA FORM 10-1436, MAY 1985,
PAGE 1
JUN 1989
WILL NOT BE USED

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