Wach Fund Application

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Wach Fund Application

  1. 1. WACH FUND APPLICATION UNIVERSITY OF ILLINOIS AT CHICAGO – COLLEGE OF DENTISTRY RESEARCH AWARDS COMMITTEEProject Title      Amount Requested       Beginning Date       Ending Date      New Faculty Yes No Is a student involved in this research? Yes NoLocation of Research Activities      INVESTIGATORSPrinciple Investigator       Social Security Number Position Title            Department       Office       Extension      Co-Investigator (1)       Social Security Number Position Title            Department       Office       Extension      Co-Investigator (2)       Social Security Number Position Title            Department       Office       Extension      Co-Investigator (3)       Social Security Number Position Title            Department       Office       Extension       Human subjects or tissues will be used. IRB Protocol Number:       (attachapproval letter) Animal subjects will be used. ACC Protocol Number:       (attach approvalletter)SIGNATURESPrinciple Investigator DateCo-Investigator (1) DateCo-Investigator (2) DateCo-Investigator (3) DateDepartment Head DateDepartment Head DateRESEARCH AWARDS COMMITTEE USE ONLY Approved – Amount Funded Deferred Unapproved
  2. 2. WACH FUND APPLICATION UNIVERSITY OF ILLINOIS AT CHICAGO – COLLEGE OF DENTISTRY RESEARCH AWARDS COMMITTEE OTHER SUPPORTFor the investigators named on the cover sheet of this application, list in separate groups: (1) allcurrently active support; and (2) all applications and proposals pending review or funding.Continuation sheets may be used as necessary.For each item give: (a) title; (b) source of support; (c) percentage of appointment on theproject; (d) dates of entire project period; and (e) annual direct costs.PRINCIPLE INVESTIGATOR(1) Current Support      (2) Pending Applications      CO-INVESTIGATOR(S)(1) Current Support      (2) Pending Applications      
  3. 3. WACH FUND APPLICATION UNIVERSITY OF ILLINOIS AT CHICAGO – COLLEGE OF DENTISTRY RESEARCH AWARDS COMMITTEE BIOGRAPHICAL SKETCHName       Position Title      EDUCATION: (Begin with Baccalaureate or other initial professional education and includepostdoctoral training)INSTITUTION AND LOCATION DEGREE YEAR FIELD OF STUDY CONFERRED                       RESEARCH AND PROFESSIONAL EXPERIENCE: Concluding with present position, list, inchronological order, previous employment and honors. List, in chronological order, the titlesand complete references to all publications pertinent to this application. A continuation pagemay be used for page two. DO NOT EXCEED TWO PAGES.     
  4. 4. WACH FUND APPLICATION UNIVERSITY OF ILLINOIS AT CHICAGO – COLLEGE OF DENTISTRY RESEARCH AWARDS COMMITTEE PROPOSED BUDGETPersonnel % Time Salary Benefits Total                                                                                        Subtotal      Equipment Total            Subtotal      Supplies Total            Subtotal      Computer Services Total            Subtotal      Travel Total            Subtotal      Other Total            Subtotal       Grand Total:      

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