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SPO #               

SCHOOL OF MEDICINE PROPOSAL ROUTING FORM
2. PI: _________________ Phone # ____________ E-Mail _________________
RPM: _________________ Phone # ____________ E-Mail _________________
1. Due Date: __________
    Dept. __________
3.       Dept. ORG code:                                      
4. P.I.   %   Effort:                  Grant    Contract #:              
5. SPONSOR NAME AND ADDRESS:




6. TITLE:
7. RESEARCH FOCUS (Check only if highly relevant to the research proposed in this application)
Human Genetics  Bioengineering  Cancer  AIDS  Bioterrorism  Satellite Embryonic Stem Cell*
8. Remarks:
9. Check One:

Research       Clinical Trial*
Instruction
Other Sponsored Activity
10. Check One: New award Supplement
  Competing Renewal Revision
  Continuation  

 
11. Proposal Period:                                       Total Budget:                               Indirect Cost Rate:
12. Project Location(s)   Bldg: ______________ Rm #: _________ Bldg: ______________ Rm #: _________
     Yes    No    
              Is all of the above space assigned to you? (If not, attach explanation from Chair.)
              Is all work supported by this proposal to be performed in my assigned laboratory space?
              Is rental space, construction or renovation required to house project?
     New rental space or renovations must be approved by School of Medicine Office of Facilities Planning and Management
YES NO   YES NO  
    13. Human Subjects     19. F & A Waived -On SU Waiver List
Yes No
    14. Laboratory Animals     20. PI Waiver Approval Received
    15. Radiological Hazards  CRA # / SMN# ______     21. Faculty Effort Waiver
    16. Recombinant DNA molecules     22. Cost Sharing
    17. Infectious or Biohazardous Agents     23. PI Completed Training
    18. Human Blood or Body Fluids      
    24. Received approval for other Department faculty effort (Include SU-42 for each department)
    25. If Human Subjects are involved, have all required personnel completed "Use of Human Subjects in Research" training?
    26. Human embryonic or fetal stem cells and/or embryo research (if yes, complete Stem Cell Research Tracking Form).
    27. Is this a "major project" as defined by A-21 allowing administrative and clerical expenses to be charged?
    28. Project involves restrictions on research participation or dissemination of results (See Openness in Research policy.)
    29. Have all participating researchers who are currently identified, including postdocs, students and visiting scholars, signed Stanford's Patent and Copyright Agreement? (SU-18 or SU-18A)
30. REMINDER: Complete and attach the Disclosure of Financial Interests Related to Research form for this proposal submission
31.PI Certification
I certify that the information I have provided about this project is accurate. Furthermore, I certify that I will direct this project in compliance with Stanford University policy, with the terms and conditions of Stanford's agreement with the sponsor, and with all applicable laws and regulations, and will uphold the responsibilities of PIship.
Signature: Date:
32.Department Approvals    
As Chair, Chief, DFA for this department I have reviewed and approved this proposal including the information listed above as required.
Chair Date:
Division Chief (if applicable) Date:
DFA or Division Administrator Date:
33. Research Process Manager's Certification
I have reviewed this proposal with the Pricipal Investigator and certify that all necessary reviews and approvals have been recieved or are currently in the review process.
Signature: Date:
34. School of Medicine Dean's Approval (If Applicable) :
Signature: Date:

SU-42/SOM/Kat   03/06