Tracking Number:
Funding Opportunity Number:
. Received Date:
PHS 398 Cover Page Supplement
OMB
Number: 0925-0001
Expiration
Date: 10/31/2018
PHS 398 Cover Page Supplement
1. Human Subjects Section
Clinical Trial?
N: No
Yes
N: No
N: No
No
*Agency-Defined
Phase III Clinical Trial?
N: No
Yes
N: No
N: No
No
2. Vertebrate Animals Section
Are vertebrate
animals euthanized?
N: No
Yes
N: No
N: No
No
If
"Yes"
to euthanasia
Is the method
consistent with American Veterinary Medical Association (AVMA)
guidelines?
N: No
Yes
N: No
N: No
No
If
"No"
to AVMA guidelines, describe method and proved scientific
justification
3. *Program Income Section
*Is program
income
anticipated during the periods for which the grant
support is
requested?
N: No
Yes
N: No
N: No
No
If you checked
"yes" above (indicating that program income is
anticipated),
then
use the format below to reflect the amount and
source(s).
Otherwise, leave this section blank.
4. Human Embryonic Stem Cells Section
*Does the proposed
project involve human embryonic stem cells?
`
Yes
N: No
No
If the proposed
project involves human embryonic stem cells, list
below the
registration number of the specific cell line(s) from
the
following list:
http://grants.nih.gov/stem_cells/registry/current.htm. Or,
if a
specific stem cell line cannot be referenced at this time,
please
check the box indicating that one from the registry will
be used:
❏
Y: Yes
Specific stem cell
line cannot be referenced at this time. One from the registry
will be used.
Cell Line(s) (Example: 0004):
5. Inventions and Patents Section (RENEWAL)
*Inventions and
Patents:
Y: Yes
Yes
N: No
No
If the answer is
"Yes"
then please answer the following:
*Previously
Reported:
Y: Yes
Yes
N: No
No
6. Change of Investigator / Change of Institution
Section
❏
Y: Yes
Change of Project
Director / Principal Investigator
Name of former
Project Director / Principal Investigator
Prefix:
*First Name:
Middle Name:
*Last Name:
Suffix:
❏
Y: Yes
Change of Grantee
Institution
*Name of former
institution:
Y: Yes
●
❍
Y: Yes
✔
/
/
1.0
0.2
*Budget Period
*Anticipated Amount
($)
*Source(s)