Pilot Project Program Cover Page Form

Once you hit 'submit' a form submission receipt will be sent to your email, if you do not receive an email within 24 hours contact pilotprojects@louisville.edu. Please include the form receipt with your full LOI application.

Your Email Address *

First and Last Name: *

Title of Project: *

Principal Investigator (list the name of the one person responsible for the scientific and ethical conduct of the project): *

Academic Rank/Position Title: *

Department of Primary Appointment: *

Telephone number: *

Email address of PI: *

Collaborator(s): *

Dates of Project (indicate beginning and ending dates for the project): *

Performance Sites (list site(s), building and rooms, where the work will be performed): *

Budget (indicate the total amount requested): *

Compliance and Training: Will the project use any of the following

Will this project use human subjects? *

IRB #

What is the status on the oversight committee?

Will this project use experimental animals? *

IACUC #

What is the status on the oversight committee?

Will this project use ionizing radition devices/isotopes? *

Please enter the registration or protocol number for Ionizing radition devices/isotopes

What is the status on the oversight committee?

Will this project use recombinant DNA? *

Please enter the registration or protocol number for Recombinant DNA

What is the status on the oversight committee?

Will this project use Pathogenic organisms? *

Please enter the registration or protocol number for Pathogenic organisms

What is the status on the oversight committee?

Will this project use CDC/USDA Select Agents? *

Please enter the registration or protocol number for CDC/USDA Select Agents

What is the status on the oversight committee?

Will this project use human blood, tissue, cell lines. OPIM? *

Please enter the registration or protocol number for Human blood, tissue, cell lines. OPIM

What is the status on the oversight committee?

Will this project use highly toxic, carcinogenic, mutagenic agents? *

Please enter the registration or protocol number for Highly toxic, carcinogenic, mutagenic agents

What is the status on the oversight committee?

Note: The P.I. is responsible for complying with University safety rules, policies and procedures

Award Type:

Career Enhancement

Interdisciplinary

New Direction

Community-Led

Envirome Institute Collaboration

Research Interest Group: Indicate the RIG(s) by checking the appropriate choice(s). (Check all that apply.)

Mechanistic and Translational Toxicology Research Interest Group

Precision Environmental Health Research Interest Group

Environmental Epidemiology and Population Health Research Interest Group

None of the above

Previous CIEHS support? *

If Yes, give the dates of the grant support periods, list the date(s) of submission of the Final Reports(s) for this (these) prior support, and provide evidence of publications and/or extramural grant applications and/or funding resulting from this support.

Principal Investigator Signature *

Principal Investigator please sign above.

Please upload a PDF file with your department chairs signature and the text: The Principal Investigator certifies that this is a new project which is not being considered for other intramural or extramural funding. The undersigned agrees to accept responsibility for the scientific and ethical conduct of the project.

Department Chair Signature *

Please upload a PDF file with your department chairs signature and the text: The Principal Investigator certifies that this is a new project which is not being considered for other intramural or extramural funding. The undersigned agrees to accept responsibility for the scientific and ethical conduct of the project.
One file only.
256 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

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