4040-0001 R&R Other Project Information

OMB Number: 4040-0001
Expiration Date: 2/28/2013

RESEARCH & RELATED Other Project Information
1. Are Human Subjects Involved?
1.a.

No

Yes

If YES to Human Subjects
Is the Project Exempt from Federal regulations?

Yes

If yes, check appropriate exemption number.
If no, is the IRB review Pending?

1

Yes

No
2

3

4

5

6

No

IRB Approval Date:
Human Subject Assurance Number:
2. Are Vertebrate Animals Used?
2.a.

Yes

No

If YES to Vertebrate Animals
Is the IACUC review Pending?

Yes

No

IACUC Approval Date:
Animal Welfare Assurance Number:
3. Is proprietary/privileged information included in the application?

Yes

No

4.a. Does this Project Have an Actual or Potential Impact - positive or negative - on the environment?

Yes

No

4.b. If yes, please explain:
4.c. If this project has an actual or potential impact on the environment, has an exemption been authorized or an environmental assessment (EA) or
environmental impact statement (EIS) been performed?
Yes
No
4.d. If yes, please explain:
5. Is the research performance site designated, or eligible to be designated, as a historic place?

Yes

No

6. Does this project involve activities outside of the United States or partnerships with international collaborators?

Yes

5.a. If yes, please explain:
No

6.a. If yes, identify countries:
6.b. Optional Explanation:
7. Project Summary/Abstract

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8. Project Narrative

10. Facilities & Other Resources

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11. Equipment

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9. Bibliography & References Cited

12. Other Attachments

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