Form 4040-0001 Research & Related Other Project Information

OMB Approval No.:4040-0001
Expiration Date: mm/dd/yyyy

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

II YES to Human Subjects

o
li::D=-v_es__..i,0=-N_
- _.

Is the Project Exempt from Federal regulations?
If yes, check appropriate exemption number.

If no, is the IRB review Pending?
IRB Approval Date: j

O Yes

2.a.

If YES to Vertebrate Animals

01 0 2 0 3 0 4 0 5 0 6

O No

--'

--,,-..::::=:;:;;;:;;=::::::::;-

[Oves

Is the IACUC review Pending?
IACUC Approval Date:!

DNo

I

Human Subject Assurance Number:

2. Are Vertebrate Animals Used?

O Yes

0 Yes

0No

ONo

l
'-------:::�---�

Animal Welfare AssuranceNumber: '---------'

3. Is proprietary/privileged information Included in the application?

...-

==r

r.:lD -Yes--,..0 N-o--,

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

4.b. Ifyes, please ex pl ain:

!O

Yes

L--------------------------------------------'

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. lfyes. please explain:

O

D

L--------------------..;;;;;:;;===.-==;;;;;--------'
!D Yes ONo

5. ls the research performance site designated. or eligible to be designated. as a historic place?
5.a. Ifyes. please explain:

�-:-:---.-.-:--:--:--:------:---:--:---:---:---:---:---;;;:;;=:::=:;;;;::;::=::::;----'
(D
D

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

No

--===========================================�

6.a. Ifyes. identify countries:

6.b. Optional Explanation:

Yes

'-------------------- ------------------- - ---

8. Project Narrative

10. Facilities & Othor Rosourcos
11. Equipment

L---------------___J
12. Other Attachments
Add Attachments
,.,. Alu 'h,·,�,,

II

Add Attachment

I I . ·� .

FIL

"ID

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 4040-0001. The time required to complete this information collection is estimated to average 1 hour per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200
Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

�