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Request Form-Let Me Help Your Project

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The Let Me Help Your Project (LMHY) Program provides funds for limited additional support, to investigators from affiliated institutions with current federal funding in health conditions affecting Hispanic population. To request our support, please complete this form and submit the required documents. If you have any question or a special request please contact: Ms. Antonia Ortiz, Pilot Project Coordinator, at antonia.ortiz@upr.edu, 787-759-0306 ext. 227.

First Name:

* must provide value

Last Name:

* must provide value

Highest Degree:

Specify, other degree:

Main Institution Affiliation:

* must provide value

Specify, other main institution:

Current Position:

Specify, other position:

Email:

* must provide value

Select the main purpose of this request.

* must provide value

Specify, other support:

Provide a brief description of the purpose to request this program (< 250 words).

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Specify the amount of funds needed without comma.

* must provide value

Upload a detailed budget justification.

* must provide value

Upload file

Study Title:

* must provide value

Research Areas:

Cancer

HIV

Neuroscience

Cardiovascular/metabolic

Emerging infection diseases

Disaster-related conditions

Other

Specify, other research area:

Provide the study abstract (< 300 words) include background, aims/objectives, materials and methods, findings, results or conclusions (if applicable), and/or how the LMHY program will help in the submission of an R grant.

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Funding Support:

NIH

Industry

CDC

SAMHSA

Other

Institutional Support

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Other, specify:

Grant/Contract number:

Institution/Agency name:

IRB/IACUC Number (if applicable):

IRB/IACUC Expiration Date (if applicable):

M-D-Y

Does this study need to recruit participants?

* must provide value

Enrollment of First Participant.

Date of the Enrollment of First Participant.

M-D-Y

The date of the enrollment of first participant reported is...

Total Number of Human Subject Expected for the entire study at your site

Please use the Targeted/Planned Enrollment Table attached.

Attachment:enrollment.doc

Please upload the Targeted/Planned Enrollment Table.

* must provide value

Upload file

Progress Report

We will request an annual progress report for each study. This information is part of NIH requirements to continue funding the Hispanic Alliance

Data Sharing

Data sharing is essential for expedited translation of research results into knowledge, product and procedures to improve human health. The National Institutes of Health (NIH) has a policy to share and make available to the public the results and accomplishments of the activities that it funds.

Compliance

Please be aware that the Hispanic Alliance is encouraging that all research activities are in compliance with the federal policies, rules and guidelines for research involving animals or subjects. For this reason, your study supported by the Hispanic Alliance needs to follow the Hispanic Alliance Standard Operational Procedures.

Acknowledgement of Support

Each publication, press release or other document that results from NIH grant supported research must include an acknowledgment of NIH grant support and disclaimer such as: "Research reported in this publication was supported by the National Institute of General Medical Sciences (NIGMS) National Institutes of Health under the Award Number U54GM133807. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health".

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I agree to fulfill these responsibilities and submit the information requested by the Hispanic Alliance in a timely manner.

Please provide an electronic signature.

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Add signature

Biographical Sketch

Â
For guidelines and Biosketch format pages and samples
access: https://grants.nih.gov/grants/forms/biosketch.htmÂ

* must provide value

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Copy of IRB/IACUC/IBC approval letter (if applicable)

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Letter of request briefly describing the rationale, methods, and the justification of how the LMHY supplement will help the advancement the project.

Upload file

*The evaluation process for this request can take between 1 to 3 working days.*

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