DAGMEC
Resident and Fellow Research Support Grant
Application Cover Page

 Instructions: Complete this form and submit with your application. Please print or type.

Principal Investigator Name: __________________________________________________________________

Department: ________________________________________________________________________________

Rank: _____________________________________________________________________________________

Signature: _________________________________________________________________________________

Co-Investigator Name:  _______________________________________________________________________

Department: ________________________________________________________________________________

Rank: ______________________________________________________________________________________

Signature: ___________________________________________________________________________________

Note: If more than two faculty are involved, list their names and department on a separate sheet.

Project Title: ______________________________________________________________________________

Amount Requested:  ______________________________

Please indicate which of the following research conditions apply to the proposed project. If your project has been reviewed and approved by the appropriate committees, note the dates.

human subjects:            Yes_____        No_____         Date approved_______________

animal subjects:             Yes_____        No_____         Date approved_______________

biohazards:                      Yes_____        No_____         Date approved_______________

radioisotopes:                Yes_____        No_____         NRC Number _______________

Endorsement of Faculty Mentor

Note to Mentor: DAGMEC Resident and Fellow Research Support Grant guidelines require that the applicant's faculty mentor endorse the proposal. The endorsement documents the mentor's support of the project and the resident or fellow's efforts on the project if the project is funded.

I endorse the project proposed in this application.

__________________________________________                  __________________________________________

Faculty Mentor (Signature)                                                                   Faculty Mentor (print name)