Grant Application Document Tracking Form
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1GAP # ___________
Reviewer: _______________________
Grant Application Document Tracking Form
Other: ____________________________
How did you hear about this opportunity:
Research Administration
The RUN
please specify
Please submit a completed & signed copy at least 4 weeks before grant deadline via e-mail to
IPR@smh.ca
Are you submitting a
Letter of Intent/Registration or
Full Grant Application?
Date Submitted: ________________
SMH Contact (questions & pick up: Name: ___________________________
Ext: ___________________
I
NVESTIGATOR INFORMATION
SMH Investigator: ________________________________
Dept: ___________________
Division: ____________________
Principal:
Co-Investigator:
Junior Investigator (<6yr faculty Appt.):
Senior Investigator:
List of other Investigators: ________________________________________________________________________________________
G
A
I
RANT
PPLICATION
NFORMATION
Study Title: ___________________________________________________________________________________________
Full Name of Funding Agency: _____________________________________________________________________________________
Funding Purpose:
Operating
Clinical Trials
Career Award
nfrastructure
Other
I
Name of Competition: __________________________________________________________________________
Application Deadline: ___________________ If awarded, Month & Date when funds will be received: _______________
Type of Application:
New
Renewal
Resubmission:
Yes
No If yes, list agencies: _______________________
Total amount Requested: ___________________________
Years Requested: ________________________
Is Administering Institution:
SMH
Other, please specify: ________________________________________________
Research Area:
Dry Bench
Clinical
Other
Basic , if basic has Research Core Facility cost been included
Yes
Will
ending
you receive equipment through this grant:
Yes
No If yes, do you have approvals and space:
Yes
No
P
: __________________
Matching funds required:
Yes
No , If Yes, approval received:
Yes
No
Pending Source & Amount
I
P
R
P
(IPRP)-
&
NTERNAL
EER
EVIEW
ROCESS
FOR ALL PEER REVIEWED GRANTING AGENCIES
OPERATING GRANTS OF NON PEER REVIEWED AGENCIES
Undergoing IPRP:
Yes
Exempt
Name of reviewers, including email address if not at SMH: 1. _________________________________________________________
2. _________________________________________________________
rd
(3
Optional)
3. ________________________________________________________
If exempt, reason:
_____________________________________
Name of organization(option 2)
Please Select
C
ONFLICT OF INTEREST
Conflict of Interest: Does the SMH Investigator or anyone on the Research Team or their family members have a financial or equity interest in the
funding agency or any organization that could benefit from the research outcomes (e.g. employment, consulting, endorsement of products to be
studied, member of senior management etc.)?
No
Yes if yes, please describe: _______________________________________________
SIGNATURES
(If human subjects and/or clinical resources are involved, both signatures are required from PI and Division Chief):
Principal Investigator Signature: _______________________________________
Date: ______________________________
Clinical Division Chief Signature: _______________________________________
Date: ______________________________
Application Approved by: __________________________________________
Date: _______________________________
Grant Application picked up by Signature: ________________________________________
Date: ______________________
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