A Curriculum for Clinical Research Training in Vermont

56个字符长度限制，包括空格。 IRG：ZHL1 SRC(99)已收到：01/15/2004 1.项目名称 佛蒙特州的临床研究培训课程 2.对申请或计划公告或征集的具体请求的响应[]否[]是 (如“是”，请述明编号及标题) 编号：HL-04-004 TIT，E：临床研究课程奖 3.首席调查员/项目主任新调查员[]否[]是 3A.姓名(姓、名、中) 利滕贝格，本杰明3b。学位(S)医学硕士 3C。职位头衔3D。邮寄地址(街道、城市、州、邮政编码) 医学教授 珍珠街371号 3E。系、服务、实验室或同等职位 佛蒙特州伯灵顿普通内科，05401 3F。主要分部 医学院 3G。电话和传真(区号、号码和分机)电子邮件地址： 电话：802-847-8268]传真：802-847-0319 J 4.人体受试者4a。研究豁免[]否[]是 脊椎动物[]不[]是 如果是，则研究是否免税否。 []4b号。人体受试者4c。NIH定义的第三阶段5a。如果是，则IACUC批准日期为5b。动物福利保障编号 []是保证否。临床试验A3301-01 FWA 00000723[]否[]是 6.拟议期间的日期7.最初请拨的费用8.请拨的费用 支助(月、日、年--月/日/年)预算期间支助期间 7A。直接成本(70亿美元)。总成本(美元)8a。直接成本($)80亿。总成本(美元) 由2005年6月1日至2010年5月31日$278,180$300,000$1,390,843$1,500,000 9.申请组织10.组织类型 名称佛蒙特州大学和州立农业公共机构：-&gt；[]联邦[]州立[]地方 私立大学：_[]私立非营利组织 地址：340沃特曼营利性组织：_-[]General[]Small Business 南展望街85号妇女拥有的社会和经济上的弱势群体 佛蒙特州伯灵顿，邮编05405-016011，实体识别号 1030179440A1 邓氏编号06-681-1191 机构配置文件编号(如果知道)会议ID受信任的VM 12.作出裁决时通知行政官员13.申请组织的正式签字 姓名：露丝·法雷尔 姓名：威廉·P！乌格，助理局长 职称导演职称 赞助项目办公室地址(_ff_&00__L_P_或_L[L_“ns 沃特曼340沃特曼 佛蒙特州大学佛蒙特州大学 佛蒙特州伯灵顿邮编：05401-0160VT 05401-0160 电话802-656-3360传真802-656-1326电话802-656-3360 电子邮件ospuvm@zoo.uvm.edu 14.首席调查员/项目主任保证：本人证明在第3a条中所列的PI/PD的签字。日期 据我所知，此处的陈述真实、完整、准确。我是 (在Inf.不接受“PER”签名。)/ 意识到任何虚假、虚构或欺诈性的陈述或声明可能会使我 *J.F.，_， 刑事、民事或行政处罚。我同意承担科学研究的责任 进行该项目，并提供所需的进度报告，如果赠款被授予为 这是一个应用的结果。 15.申请组织认证和验收：本人证明日期 据我所知，以下陈述真实、完整、准确，并且 接受遵守公共卫生服务条款和条件的义务 作为这项申请的结果被授予。我知道任何虚假、虚构或欺诈性的 声明或索赔可能会使我受到刑事、民事或行政处罚。 小灵通398(05/01版首页表格第1页

56-character length restrictions, including spaces. IRG: ZHL1 SRC(99) Received: 01/15/2004 1. TITLE OF PROJECT A Curriculum for Clinical Research Training in Vermont 2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION [] NO [] YES (If "Yes," state number and title) Number: HL-04-004 Tit,e:Clinical Research Curriculum Award 3. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR New Investigator [] No [] Yes 3a. NAME (Last, first, middle) Littenberg, Benjamin 3b. DEGREE(S)MD I 3c. POSITION TITLE 3d. MAILING ADDRESS (Street, city, state, zip code) Professor of Medicine 371 Pearl Street 3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT Division of General Internal Medicine Burlington, VT 05401 3f. MAJOR SUBDIVISION College of Medicine 3g. TELEPHONE AND FAX (Area code, number and extension) E-MAIL ADDRESS: TEL: 802-847-8268 ] FAX: 802-847-0319 Benjamin.Littenberg@UVM.edu J 4. HUMAN SUBJECTS 4a. Research Exempt[] No [] Yes 5. VERTEBRATE ANIMALS [] No [] Yes RESEARCH If "Yes,"Exemption No. [] No 4b. Human Subjects 4c. NIH-defined Phase III 5a. If"Yes," IACUC approval Date 5b. Animal welfare assurance no [] Yes AssuranceNo. Clinical Trial A3301-01 FWA 00000723 [] No [] Yes 6. DATES OF PROPOSED PERIOD OF 7. COSTS REQUESTED FOR INITIAL 8. COSTS REQUESTED FOR PROPOSED SUPPORT (month, day, year--MM/DD/YY) BUDGET PERIOD PERIOD OF SUPPORT 7a. Direct Costs ($) 7b. Total Costs ($) 8a. Direct Costs ($) 8b. Total Costs ($) From 06/01/05 J Through05/31/10 $278,180 $300,000 $1,390,843 $1,500,000 9. APPLICANT ORGANIZATION 10. TYPE OF ORGANIZATION Name University of Vermont and State Agricultural Public: ---> [] Federal [] State [] Local College Private: _ [] Private Nonprofit Address 340 Waterman For-profit: _-+ [] General [] Small Business 85 South Prospect Street [] Woman-owned _[] Socially and Economically Disadvantaged Burlington, Vermont 05405-0160 11, ENTITY IDENTIFICATION NUMBER 1030179440A1 DUNS NO. 06-681-1191 Institutional Profile File Number (if known) CongressionaIDistrict vm 12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE 13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION Name Ruth Farrell Name William P!oog, Assistant Director Title Director Title Address Office of Sponsored Programs Address (_ff_& 00_ _l_P_or_l[l_"ns 340 Waterman 340 Waterman University of Vermont University of Vermont Burlington, VT 05401-0160 Burlington, VT 05401-0160 Telephone 802-656-3360 FAX 802-656-1326 Telephone 802-656-3360 FAX 802-656-1326 E-Mail ospuvm@zoo.uvm.edu E-Mail ospuvm@zoo.uvm.edu 14. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE: I certify that the SIGNATURE OF PI/PD NAMED IN 3a. DATE statements herein are true, complete and accurate to the best of my knowledge. I am (In inF. "Per" signature not acceptable.) / aware that any false, fictitious, or fraudulent statements or claims may subject me to ¿ j.f,_ , criminal, civil, or administrative penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of this a.Eplication. 15. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: Icertify that the DATE statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with Public Health Services terms and conditions if a grant is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal,civil, or administrative penalties. PHS 398 (Rev. 05/01 Face Page Form Page 1