Principal Investigator Name *

First Name

Last Name

Phone *

Office Phone Number

(###)

###

####

Principal Investigator is a VA employee? *

Yes

No

Type of Proposal *

Please indicate whether this is a prime proposal (BVARI will submit directly to the granting agency) a subaward proposal (BVARI will be a subaward under another institution) or an industry sponsor/CRADA proposal.

Prime Proposal

Subaward Proposal (please enter institution name, PI name, and grants admin contact for prime/lead institution below):

Industry Sponsor/CRADA or Foundation

Proposal Deadline *

MM

DD

YYYY

Period of Performance Start Date *

MM

DD

YYYY

Period of Performance End Date *

MM

DD

YYYY

Planned Participation in Additional Compensation? *

Yes

No

Compliance *

Check all that apply.

Human Subjects

Animal Subjects

Veterans-related project

Educational Program

International Collaboration

QA/QI

VA Service Impact

Check all that apply.

Pharmacy Costs

Clinical Costs

Imaging Costs

Other

Certification *

As the proposed PI on this project, I certify that all information is accurate to the best of my knowledge.