Revised 398 Cover Page Supplement

PHS 398 Cover Page Supplement

OMB Number: 0925-0001

1. Project Director/Principal Investigator (PD/PI)

Prefix

*First Name

Middle Name

*Last Name

Suffix

2. Human Subjects

Clinical Trial?

*Agency-defined Phase III Clinical Trial?

3. *Disclosure Permission Statement

If this application does not result in an award, is the Government permitted to disclose the title of the proposed project, and the name, address, telephone number, and e-mail address of the official signing for the applicant organization, to organizations that may be interested in contacting you for further information (e.g. possible collaborations, investment)?

4. *Program Income

*Is the program income anticipated during the periods for which the grant support is requested?

If you checked “Yes” above (indicating that program income is anticipated), then use the format below to reflect the amount and source(s). Otherwise leave this section blank.

*Budget Period

*Anticipated Amount ($)

*Source(s)

5. Human Embryonic Stem Cells

*Does the proposed project involve human embryonic stem cells?

If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list: http://stemcells.nih.gov/research/registry/. Or, if a specific stem cell line cannot be referenced at this time, please check the box indicating that one from the registry will be used:

Cell Line(s)

6. Inventions and Patents (For renewal applications only)

*Inventions and Patents

If the answer is “Yes” then please answer the following:

*Previously Reported

7. Change of Investigator/Change of Institution Questions

Name of former principal investigator/program director

Prefix

* First Name

Middle Name

*Last Name

Suffix

*Name of former institution