MGH Biostatistics Proposal Intake Form MGB Username(Required) Email Address(Required) NIH eRA Commons Username (if known) Is your agreement a subcontract under another organization's award?(Required) Yes No Funding Sponsor(Required)e.g. NIH, NSF, DoD, etc. Sponsor due date(Required) MM slash DD slash YYYY Note: The Biostatistics Director will be notified if the sponsor deadline listed is fifteen (15) business days or fewer from the date this form is submitted.PI Name(Required) Project Title(Required) Proposed Project Start Date MM slash DD slash YYYY Proposed Project End Date MM slash DD slash YYYY Proposal Type(Required) New Resubmission Renewal Will there be any subcontracts?(Required) Yes No Subcontracts: If yes, please list contact information for PI and their grant administrator contact details (name/email)(Required) Subcontracts: Is the subrecipient performing Human Subjects Research?(Required) Yes No If yes, is the subrecipient's human research activity exempt?(Required) Yes No Subcontracts: Is the subrecipient receiving or sending any human subjects data or materials as part of the project?(Required) Yes No If yes, please describe the transfer process of data/samples:(Required)Subcontracts: Is the subrecipient using vertebrate animals as part of the project?(Required) Yes No Provide IACUC Assurance #:(Required) Subcontracts: Is the subrecipient using Human Embryonic Stem Cells as part of the project?(Required) Yes No Please list the Funding Opportunity Annoucement (URL) Does the PI have a VA Appointment?(Required) Yes No Is this a Multi-PI proposal?(Required) Yes No Is this project related to COVID-19/coronavirus?(Required) Yes No At this time, will your application have Direct Costs of $500K or more in any one year?(Required) Yes No Undetermined Key Personnel on the grant (Name and Perfect Effort):(Required)First and Last NamePercent Effort Add RemoveClick the + icon to add more rows.Compliance QuestionsDoes this project include the use of Human Subjects(Required) Yes No Does this project include a clinical trial?(Required) Yes No Is the protocol oversight at Mass General Brigham IRB office?(Required) Yes No If yes, what year of your project does the IRB protocol work begin?(Required) Will non-Mass General Brigham institutions rely on Mass General Brighan IRB for protocol oversight (e.g. if Single IRB policy applies)?(Required) Yes No If no, please provide the name of the external institution that will provide IRB oversight:(Required) Does this project include the use of animals?(Required) Yes No If yes, is the protocol oversight at Mass General Brigham IACUC committee?(Required) Yes No What year of your project does the IACUC protocol work begin?(Required) Please provide the name of the external institution that will provide IACUC oversight:(Required) Does this project include the use of Biohazard Materials (infectious agent/human materials)?(Required) Yes No Has this study been submitted to Biosafety Committee?(Required) Yes No When do you intend to submit to IBC?(Required) Does this project contain Radiation/Isotope use?(Required) Yes No Please enter a permit #:(Required) Is this project cancer related?(Required) Yes No Does this project include the use of Human Embryonic Stem Cells?(Required) Yes No Will information, materials or equipment be shipped/transmitted (e.g. via email) outside the country?(Required) Yes No Does this project involve activities outside of the U.S. or partnerships with international collaborators? Answer yes if the project involves a foreign component.(Required) Yes No If yes, please describe:(Required)Additional Information:EmailThis field is for validation purposes and should be left unchanged.
