CCEB Grant Registration Form

Instructions: Please complete this form and click on the "Submit" button below. Someone will contact you regarding your submission within two business days.
Please read this document before submitting a request.

CCEB Senior Scholar:
	Last Name	First Name

Submitting Unit:	Biostatistics Epidemiology

Proposal Information:
Date application to be submitted (mm/dd/yyyy):
Anticipated date of funding (mm/dd/yyyy):
Anticipated start date of project (mm/dd/yyyy):
Anticipated start date of data collection (mm/dd/yyyy):
Will data be collected at, or transmitted from, sites outside the University of Pennsylvania Health System and/or Delaware Valley Case Control Network?
Yes No Not Sure

Sponsor (e.g., NIH, AHA, etc.):
Sponsor Contact Information:
Name:
Phone Number:
E-mail:
Sponsor URL:
Is this a subcontract from another institution?	Yes No
*Title:
*Funding Mechanism:
	(e.g., R01, P01, SCOR, Industry)
Are you responding to an FOA?	Yes No If yes, supply the number:
Grant Type:	New Resubmission Non-competing Renewal
Length of Project:	Years
Total Costs (if budget cap):	Year 01 All Years
Indirect Cost Rate:	Federal Overhead Rate Clinical Trial Overhead Rate Other Overhead Rate (specify):
Any subcontracts to other institutions on the project?	Yes No
If yes, please provide name of the institution, subcontract PI, and contact person:
Brief Project Description (one to two sentences):
Do you want to upload the non-budgeted information?	Yes No

Principal Investigator Information:
Name:
	Last Name	First Name
Department:
Division:
Other than the PI, who is approved to see the budget information, including salaries?

Collaborative Personnel and Resource Needs
Biostatistics Faculty Consultation Required?	Yes No
If yes, have you contacted a biostatistics faculty member?	Yes No
If yes, name of biostatistics faculty member already contacted:	Last Name	First Name
MS Biostatisticians (BAC):	Yes No
Data Management and/or Computing Personnel (CRCU):	Yes No

Project Information
Project type (please check all that apply):
	Survey
	Case-control
	Prospective cohort
	Retropective cohort
	Randomized Clinical Trial
	Other (specify):

*Send confirmation email to:
* = Required field