Please provide the following information. If you have any questions or concerns regarding your request, you may contact Ms. Antonia L Ortiz, antonia.ortiz@upr.edu .
IMPORTANT:
Please do not forget to click "Submit" if you completed this form or "Save and Return Later" if you need to complete the form at a later time. If you click on "Save and Return Later", you need to WRITE DOWN AND SAVE the "Return Code" in a secure place. This will ensure that the information entered in the form will be saved. If you have problems returning to the saved but partially completed online form, please contact Dr. Carlamarie Noboa carla.noboa@upr.edu who will provide you with the required access to finalize your online form.
This project is proposing a Multi-PIs?
* must provide value
No
Yes
PI last name:
* must provide value
PI first name:
* must provide value
PI main academic institution:
* must provide value
UPR-MSC UPR-CCC UCC PHSU SJBSM VACHS Other
Other main academic institution, specify:
PI main school affiliation:
* must provide value
Medicine Pharmacy Nursing Dental Public Health Health Professions Other
PI academic appointment:
* must provide value
Instructor Adjunct Professor Assistant Professor Associate Professor Professor Other
Other academic appointment, specify:
No Yes
Early stage investigators are considered those investigators with more than 10 years after his/her completed high professional degree or after his/her completed medical residence (or the equivalent).
PI highest academic degree:
* must provide value
PhD MD MD/PhD PsyD DrPh DMD DVD EdD ScD Other
Other highest degree, specify:
PI email:
* must provide value
Please upload the most recent NIH Biosketch of the Principal Investigator. NEW. All biosktechs MUST follow the new NIH format page guidelines. See link below for instructions and forms. https://grants.nih.gov/grants/forms/biosketch.htm
* must provide value
(Latest version, not exceed 5 pages for each person).
PI last name:
* must provide value
PI first name:
* must provide value
PI main academic institution:
* must provide value
UPR-MSC UPR-CCC UCC PHSU SJBSM VACHS Other
Other main academic institution, specify:
PI main school affiliation:
* must provide value
Medicine Pharmacy Nursing Dental Public Health Health Professions Other
PI academic appointment:
* must provide value
Instructor Adjunct Professor Assistant Professor Associate Professor Professor Other
Other academic appointment, specify:
PI highest academic degree:
* must provide value
PhD MD MD/PhD PsyD DrPh DMD DVD EdD ScD Other
Other highest degree, specify:
PI is an early stage investigator?
* must provide value
No Yes
Early stage investigators are considered those investigators with more than 10 years after his/her completed high professional degree or after his/her completed medical residence (or the equivalent).
PI email:
* must provide value
PI phone number:
* must provide value
Please upload the most recent NIH Biosketch of the Principal Investigator. NEW. All biosktechs MUST follow the new NIH format page guidelines. See link below for instructions and forms.https://grants.nih.gov/grants/forms/biosketch.htm
* must provide value
(Latest version, not exceed 5 pages for each person).
How many mentors include the proposed project?
* must provide value
1
2
3
Mentor last name:
* must provide value
Mentor first name:
* must provide value
Mentor main academic institution:
* must provide value
UPR-MSC UPR-CCC UCC PHSU SJBSM VACHS Other
Other main academic institution, specify:
Mentor highest academic degree:
* must provide value
PhD MD MD/PhD PsyD DrPh DMD DVD EdD ScD Other
Other highest degree, specify:
Mentor email:
* must provide value
(Latest version, not exceed 5 pages for each person).
Please upload the letter of support from the mentor (max. 1 page).
* must provide value
Mentor last name:
* must provide value
Mentor first name:
* must provide value
Mentor main academic institution:
* must provide value
UPR-MSC UPR-CCC UCC PHSU SJBSM VACHS Other
Other main academic institution, specify:
Mentor highest academic degree:
* must provide value
PhD MD MD/PhD PsyD DrPh DMD DVD EdD ScD Other
Other highest degree, specify:
Mentor email:
* must provide value
(Latest version, not exceed 5 pages for each person).
Please upload the letter of support from the mentor (max. 1 page).
* must provide value
Mentor last name:
* must provide value
Mentor first name:
* must provide value
Mentor main academic institution:
* must provide value
UPR-MSC UPR-CCC UCC PHSU SJBSM VACHS Other
Other main academic institution, specify:
Mentor highest academic degree:
* must provide value
PhD MD MD/PhD PsyD DrPh DMD DVD EdD ScD Other
Other highest degree, specify:
Mentor email:
* must provide value
(Latest version, not exceed 5 pages for each person).
Please upload the letter of support from the mentor (max. 1 page).
* must provide value
How many Co-Investigators include this project?
* must provide value
0
1
2
3
Co-I first name:
* must provide value
Co-I last name:
* must provide value
Co-I main academic institution:
* must provide value
UPR-MSC UPR-CCC UCC PHSU SJBSM VACHS Other
Other main institution, specify:
Co-I highest academic degree:
* must provide value
PhD MD MD/PhD PsyD DrPh DMD DVD EdD ScD Other
Other highest degree, specify:
Co-I email:
* must provide value
(Latest version, not exceed 5 pages for each person).
Co-I last name:
* must provide value
Co-I first name:
* must provide value
Co-I main academic institution:
* must provide value
UPR-MSC UPR-CCC UCC PHSU SJBSM VACHS Other
Other main institution, specify:
Co-I highest academic degree:
* must provide value
PhD MD MD/PhD PsyD DrPh DMD DVD EdD ScD Other
Other highest degree, specify:
Co-I email:
* must provide value
(Latest version, not exceed 5 pages for each person).
Co-I last name:
* must provide value
Co-I first name:
* must provide value
Co-I main academic institution:
* must provide value
UPR-MSC UPR-CCC UCC PHSU SJBSM VACHS Other
Other main institution, specify:
Co-I highest academic degree:
* must provide value
PhD MD MD/PhD PsyD DrPh DMD DVD EdD ScD Other
Other highest degree, specify:
Co-I email:
* must provide value
(Latest version, not exceed 5 pages for each person).
Title of the project:
* must provide value
Health conditions proposed to study:
* must provide value
Other health condition, specify:
Does the proposal include any of the following collaborations?
* must provide value
Others collaborations, specify:
Could be a name of an organization, project, program, coalition, etc.
Full name of the primary contact from the community
(Last Name, First Name)
Primary contact phone number
This project will require approvals from:
Others approvals, specify:
Specify the status of IRB requirements:
* must provide value
Submitted Approved To be submitted
Specify the status of IACUC requirements:
* must provide value
Submitted Approved To be submitted
Specify the status of Biosafety requirements:
* must provide value
Submitted Approved To be submitted
Abstract of the study - 250 words include career development plan objectives.
* must provide value
Statement of the problem - equivalent of the Specific Aim page. State the purpose of the research. PI must include the problem to be studied, explain why this problem need to be investigated, and how the study findings will address the problem. Include supporting documentation.
* must provide value
(1-2 paragraphs)
Goal statement and hypothesis - Include the research question. This section must answer the "who, what, and why" .
* must provide value
(1 paragraph)
Rationale of the study -This section will determine how strong the concept paper is. Include significance and innovation. Preliminary data is not required but may be included.
(2-3 paragraphs)
Methodology - Include study population and sample size and study design.
(1 paragraph)
Career development plan - (main objectives) Specify the main objectives or skill to acquire. This may include topic areas to learn, new techniques skills, and other learning/educational activities.
* must provide value
(1 paragraph)
Please upload the timeline - earliest starting date is July 2024.
Please list the references.
Submit
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