Advanced Technology Program

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RESEARCH & RELATED Other Project Information
1. * Are Human Subjects Involved?
1.a

Yes

No

If YES to Human Subjects
Yes

Is the IRB review Pending?

No

IRB Approval Date:
Exemption Number:

1

2

3

4

5

6

Human Subject Assurance Number:
2. * Are Vertebrate Animals Used?
2.a.

Yes

No

If YES to Vertebrate Animals
Is the IACUC review Pending?

Yes

No

IACUC Approval Date:
Animal Welfare Assurance Number
3. * Is proprietary/privileged information included in the application?

Yes

4.a. * Does this project have an actual or potential impact on the environment?

No
Yes

No

4.b. If yes, please explain:
4.c. If this project has an actual or potential impact on the environment, has an exemption been authorized or an environmental assessment (EA) or
environmental impact statement (EIS) been performed?
Yes
No
4.d. If yes, please explain:
5.a. * Does this project involve activities outside the U.S. or partnership with International Collaborators?

Yes

No

5.b. If yes, identify countries:
5.c. Optional Explanation:
6. * Project Summary/Abstract

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7. * Project Narrative
8. Bibliography & References Cited

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10. Equipment

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9. Facilities & Other Resources

11. Other Attachments

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OMB Number: 4040-0001
Expiration Date: 04/30/2008