PI Name: ______ , ______ ______
Today M-D-Y
PI's Member ID (NNECTR Registration)
For use in data linkage
What is the title of the proposed research project?
* must provide value
What is the award category (or categories) of the proposed research project?
Has this proposal been submitted previously? Please mark "yes" only if the proposal has previously been submitted under the same title with the same research team.
* must provide value
Yes No
Will the project involve key personnel from multiple institutions?
* must provide value
Yes No
Institutions Involved.
* must provide value
Did the PI or other team members use Research Navigation/Research Catalyst services to assist in the preparation of this LOI?
* must provide value
Yes No
Please check the name(s) of the Research Navigator(s) / Catalyst(s) who provided assistance:
Does the PI intend to use Research Navigation/Research Catalyst services to prepare the full proposal for this project?
* must provide value
Yes No
How did you hear about this pilot funding opportunity ?
* must provide value
Word-of-mouth/colleague
Email announcement from NNE-CTR
Twitter announcement from NNE-CTR
NNE-CTR website
Other
Please complete the full set of questions for each key personnel, beginning with the Principal Investigator(s).
The first key personnel listed will serve as the primary contact for communication related to this proposal. registered with the NNE-CTR prior to submitting the LOI.
It is required that at least one member of a team hold a faculty or affiliate appointment. If junior faculty are submitting an application, please include their mentor(s) in the list of key personnel.
PI First Name
* must provide value
PI Last Name
* must provide value
PI Email Address
* must provide value
Professor Assistant Professor Resident Attending Director Postdoc Other
What is ______ 's highest degree?
PhD / ScD MD or DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
Will ______ serve in any additional roles for the proposed research project?
Yes No
Please select the additional role(s)
Is ______ currently receiving research mentoring?
Yes
No
Please enter both first and last name
New Investigator Early Stage Investigator Early Established Investigator (EEI) None of the above
With what institution is ______ primarily affiliated?
* must provide value
UVM College of Medicine Other UVM College UVM Medical Center UVM Health Network Maine Medical Center / MaineHealth University of Maine - Orono University of Southern Maine Dartmouth / Geisel School of Medicine Tufts University University of New England University of New Hampshire Other
Which Maine Medical Center department or center is ______
Anesthesiology and Perioperative Medicine Cardiac Services Critical Care Emergency Medicine Family Medicine Medicine Internal Medicine Obstetrics - Gynecology Pathology & Lab Med Pediatrics Psychiatry Radiology Surgery Maine Medical Center Research Institute Center for Outcomes Research and Evaluation Other
Which USM College or department or center is ______
Muskie School of Public Service School of Nursing School of Social Work School of Business School of Education and Human Development University of Maine Law School Other
Which UVM Medical Center/UVM College of Medicine department is ______
Anesthesiology Biochemistry Family Medicine Medicine Microbiology and Molecular Genetics Molecular Physiology and Biophysics Neurological Sciences Obstetrics Gynecology and Reproductive Sciences Orthopaedics and Rehabilitation Pathology and Laboratory Medicine Pediatrics Pharmacology Psychiatry Radiology Surgery Area Health Education Centers (AHEC) Cancer Center
Please list any additional institutional affiliations for ______ , if applicable:
Use commas to separate multiple values.
Key Personnel 2 - First Name
Key Personnel 2 - Last Name
Key Personnel 2 - Email address
What is ______ 's highest degree?
PhD / ScD MD or DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
Please select role(s) ______ will fulfill for the proposed research project
Is ______ currently receiving research mentoring?
Yes
No
Please enter both first and last name
New Investigator Early Stage Investigator Early Established Investigator (EEI) None of the above
With what institution is ______ primarily affiliated?
UVM College of Medicine Other UVM College UVM Medical Center UVM Health Network Maine Medical Center / MaineHealth University of Maine - Orono University of Southern Maine Dartmouth / Geisel School of Medicine Tufts University University of New England University of New Hampshire Other
Which Maine Medical Center department or center is ______
Anesthesiology and Perioperative Medicine Cardiac Services Critical Care Emergency Medicine Family Medicine Medicine Internal Medicine Obstetrics - Gynecology Pathology & Lab Med Pediatrics Psychiatry Radiology Surgery Maine Medical Center Research Institute Center for Outcomes Research and Evaluation Other
Which USM College or department or center is ______
Muskie School of Public Service School of Nursing School of Social Work School of Business School of Education and Human Development University of Maine Law School Other
Which UVM Medical Center/UVM College of Medicine department is ______
Anesthesiology Biochemistry Family Medicine Medicine Microbiology and Molecular Genetics Molecular Physiology and Biophysics Neurological Sciences Obstetrics Gynecology and Reproductive Sciences Orthopaedics and Rehabilitation Pathology and Laboratory Medicine Pediatrics Pharmacology Psychiatry Radiology Surgery Area Health Education Centers (AHEC) Cancer Center
Please list any additional institutional affiliations for ______ , if applicable:
Use commas to separate multiple values.
Key Personnel 3 - First Name
Key Personnel 3 - Last Name
Key Personnel 3 - Email address
What are ______ 's highest degree?
PhD / ScD MD or DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
Please select role(s) ______ will fulfill for the proposed research project
New Investigator Early Stage Investigator Early Established Investigator (EEI) None of the above
Is ______ currently receiving research mentoring?
Yes
No
Please enter both first and last name
With what institution is ______ primarily affiliated?
UVM College of Medicine Other UVM College UVM Medical Center UVM Health Network Maine Medical Center / MaineHealth University of Maine - Orono University of Southern Maine Dartmouth / Geisel School of Medicine Tufts University University of New England University of New Hampshire Other
Which Maine Medical Center department or center is ______
Anesthesiology and Perioperative Medicine Cardiac Services Critical Care Emergency Medicine Family Medicine Medicine Internal Medicine Obstetrics - Gynecology Pathology & Lab Med Pediatrics Psychiatry Radiology Surgery Maine Medical Center Research Institute Center for Outcomes Research and Evaluation Other
Which USM College or department or center is ______
Muskie School of Public Service School of Nursing School of Social Work School of Business School of Education and Human Development University of Maine Law School Other
Which UVM Medical Center/UVM College of Medicine department is ______
Anesthesiology Biochemistry Family Medicine Medicine Microbiology and Molecular Genetics Molecular Physiology and Biophysics Neurological Sciences Obstetrics Gynecology and Reproductive Sciences Orthopaedics and Rehabilitation Pathology and Laboratory Medicine Pediatrics Pharmacology Psychiatry Radiology Surgery Area Health Education Centers (AHEC) Cancer Center
Please list any additional institutional affiliations for ______ , if applicable:
Use commas to separate multiple values.
Key Personnel 4 - First Name
Key Personnel 4 - Last Name
Key Personnel 4 - Email address
What is ______ 's highest degree?
PhD / ScD MD or DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
Please select role(s) ______ will fulfill for the proposed research project
New Investigator Early Stage Investigator Early Established Investigator (EEI) None of the above
Is ______ currently receiving research mentoring?
Yes
No
Please enter both first and last name
With what institution(s) is ______ primarily affiliated?
UVM College of Medicine Other UVM College UVM Medical Center UVM Health Network Maine Medical Center / MaineHealth University of Maine - Orono University of Southern Maine Dartmouth / Geisel School of Medicine Tufts University University of New England University of New Hampshire Other
Which Maine Medical Center department or center is ______
Anesthesiology and Perioperative Medicine Cardiac Services Critical Care Emergency Medicine Family Medicine Medicine Internal Medicine Obstetrics - Gynecology Pathology & Lab Med Pediatrics Psychiatry Radiology Surgery Maine Medical Center Research Institute Center for Outcomes Research and Evaluation Other
Which USM College or department or center is ______
Muskie School of Public Service School of Nursing School of Social Work School of Business School of Education and Human Development University of Maine Law School Other
Which UVM Medical Center/UVM College of Medicine department is ______
Anesthesiology Biochemistry Family Medicine Medicine Microbiology and Molecular Genetics Molecular Physiology and Biophysics Neurological Sciences Obstetrics Gynecology and Reproductive Sciences Orthopaedics and Rehabilitation Pathology and Laboratory Medicine Pediatrics Pharmacology Psychiatry Radiology Surgery Area Health Education Centers (AHEC) Cancer Center
Please list any additional institutional affiliations for ______ , if applicable:
Use commas to separate multiple values.
Key Personnel 5 - First Name
Key Personnel 5 - Last Name
Key Personnel 5 - Email address
What is ______ 's highest degree?
PhD / ScD MD or DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
Please select role(s) ______ will fulfill for the proposed research project
New Investigator Early Stage Investigator Early Established Investigator (EEI) None of the above
Is ______ currently receiving research mentoring?
Yes
No
Please enter both first and last name
With what institution is ______ primarily affiliated?
UVM College of Medicine Other UVM College UVM Medical Center UVM Health Network Maine Medical Center / MaineHealth University of Maine - Orono University of Southern Maine Dartmouth / Geisel School of Medicine Tufts University University of New England University of New Hampshire Other
Which Maine Medical Center department or center is ______
Anesthesiology and Perioperative Medicine Cardiac Services Critical Care Emergency Medicine Family Medicine Medicine Internal Medicine Obstetrics - Gynecology Pathology & Lab Med Pediatrics Psychiatry Radiology Surgery Maine Medical Center Research Institute Center for Outcomes Research and Evaluation Other
Which USM College or department or center is ______
Muskie School of Public Service School of Nursing School of Social Work School of Business School of Education and Human Development University of Maine Law School Other
Which UVM Medical Center/UVM College of Medicine department is ______
Anesthesiology Biochemistry Family Medicine Medicine Microbiology and Molecular Genetics Molecular Physiology and Biophysics Neurological Sciences Obstetrics Gynecology and Reproductive Sciences Orthopaedics and Rehabilitation Pathology and Laboratory Medicine Pediatrics Pharmacology Psychiatry Radiology Surgery Area Health Education Centers (AHEC) Cancer Center
Please list any additional institutional affiliations for ______ , if applicable:
Use commas to separate multiple values.
Key Personnel 6 - First Name
Key Personnel 6 - Last Name
Key Personnel 6 - Email address
What is ______ 's highest degree?
PhD / ScD MD or DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
Please select role(s) ______ will fulfill for the proposed research project
New Investigator Early Stage Investigator Early Established Investigator (EEI) None of the above
Is ______ currently receiving research mentoring?
Yes
No
Please enter both first and last name
With what institution is ______ primarily affiliated?
UVM College of Medicine Other UVM College UVM Medical Center UVM Health Network Maine Medical Center / MaineHealth University of Maine - Orono University of Southern Maine Dartmouth / Geisel School of Medicine Tufts University University of New England University of New Hampshire Other
Which Maine Medical Center department or center is ______
Anesthesiology and Perioperative Medicine Cardiac Services Critical Care Emergency Medicine Family Medicine Medicine Internal Medicine Obstetrics - Gynecology Pathology & Lab Med Pediatrics Psychiatry Radiology Surgery Maine Medical Center Research Institute Center for Outcomes Research and Evaluation Other
Which USM College or department or center is ______
Muskie School of Public Service School of Nursing School of Social Work School of Business School of Education and Human Development University of Maine Law School Other
Which UVM Medical Center/UVM College of Medicine department is ______
Anesthesiology Biochemistry Family Medicine Medicine Microbiology and Molecular Genetics Molecular Physiology and Biophysics Neurological Sciences Obstetrics Gynecology and Reproductive Sciences Orthopaedics and Rehabilitation Pathology and Laboratory Medicine Pediatrics Pharmacology Psychiatry Radiology Surgery Area Health Education Centers (AHEC) Cancer Center
Please list any additional institutional affiliations for ______ , if applicable:
Use commas to separate multiple values.
Key Personnel 7 - First Name
Key Personnel 7 - Last Name
Key Personnel 7 - Email address
What is ______ 's highest degree?
PhD / ScD MD or DO DDS/DMD DNP/DNSc DPM or DP/Pod.D. DrPH/DPH JD PharmD MPH MS/MSN MSW/MEd MPAS BS/BA/BSN Other
Please select role(s) ______ will fulfill for the proposed research project
New Investigator Early Stage Investigator Early Established Investigator (EEI) None of the above
Is ______ currently receiving research mentoring?
Yes
No
Please enter both first and last name
With what institution is ______ primarily affiliated?
UVM College of Medicine Other UVM College UVM Medical Center UVM Health Network Maine Medical Center / MaineHealth University of Maine - Orono University of Southern Maine Dartmouth / Geisel School of Medicine Tufts University University of New England University of New Hampshire Other
Which Maine Medical Center department or center is ______
Anesthesiology and Perioperative Medicine Cardiac Services Critical Care Emergency Medicine Family Medicine Medicine Internal Medicine Obstetrics - Gynecology Pathology & Lab Med Pediatrics Psychiatry Radiology Surgery Maine Medical Center Research Institute Center for Outcomes Research and Evaluation Other
Which USM College or department or center is ______
Muskie School of Public Service School of Nursing School of Social Work School of Business School of Education and Human Development University of Maine Law School Other
Which UVM Medical Center/UVM College of Medicine department is ______
Anesthesiology Biochemistry Family Medicine Medicine Microbiology and Molecular Genetics Molecular Physiology and Biophysics Neurological Sciences Obstetrics Gynecology and Reproductive Sciences Orthopaedics and Rehabilitation Pathology and Laboratory Medicine Pediatrics Pharmacology Psychiatry Radiology Surgery Area Health Education Centers (AHEC) Cancer Center
Please list any additional institutional affiliations for ______ , if applicable:
Use commas to separate multiple values.
Do any of the investigators have current or pending awards for this or similar research projects?
* must provide value
Yes No
Today M-D-Y
Today M-D-Y
If any investigators have
Formats accepted: Microsoft Word (.doc or .docx ) or PDF (.pdf)
Which regulatory approvals will be necessary? Applicants are strongly urged to consult with relevant NNE-CTR Cores for projects involving subject patients for
* must provide value
Has IRB submission been initiated?
Yes No
Will assistance with IRB submission be needed?
Yes No
Has IACUC submission been initiated?
Yes No
Will assistance with IACUC be needed?
Yes No
Has IBC submission been initiated?
Yes No
Will assistance with IBC submission be needed?
Yes No
Which NNE-CTR shared resources will be used?
Research supported by these awards must utilize NNE-CTR Core Facilities on a preferential basis. Awarded funds cannot be used to support external services if these services are available at UVM. NNE-CTR website . If you are unsure about what resources are available or may be needed, please check the "Not sure" answer option below.
* must provide value
Lay Summary: Please provide a three or four sentence description of the proposed research that summarizes the focus and relevance of the project to the NNE-CTR mission in non-scientific terms such that might be used for a general interest announcement.
* must provide value
Letter of Intent
The LOI should be limited to Names of Principal Investigator, Co- Investigator and/or Mentor and their institutional affiliations Title of proposal Brief statement describing rationale for study and hypothesis to be tested. List Aims of Study. For each aim, indicate the question being addressed, the proposed approach, and the intended outcome. Impact, deliverable and/or other key details. Please upload the LOI using the link below. * must provide value
Formats accepted: Microsoft Word (.doc or .docx ) or PDF (.pdf)
When your information is complete and your LOI has been successfully uploaded, please hit the
Submit
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