Fill and Sign the Relay for Life Permission Form

Date Submitted: 4/1/14 Proposal Type: If renewal, current grant: Resubmission? American Cancer Society Physician Training Award in Cancer Prevention Grant Application Comm Code: 1st or 2nd: TITLE OF PROJECT (Titles exceeding 81 characters, including spaces and punctuation, will be truncated.) Physician Training Award in Cancer Prevention APPLICANT NAME HIGHEST DEGREE(S) POSITION TITLE: APPLICANT’S CURRENT INSTITUTION ACADEMIC RANK: DIVISION: MAILING ADDRESS (Street, city, state, postal code, country) DEPARTMENT: E-MAIL ADDRESS: Tel: Fax: PROGRAM ELIGIBILITY INFORMATION: (Responses to selected fields displayed below. For some grant programs this section may be blank.) U.S. Citizenship: Non-U.S. Citizen R esp onding t o RF A? R F A T i tle: DATES OF PROPOSED PROJECT (MM/DD/YYYY) Through 1/1/15 PROPOSED BUDGET 6/30/18 PL From E 6. Health Professional Training Grants in Cancer Control $300,000 SIGNING OFFICIAL FOR Name Name Title Tel: EIN DUNS HUMAN SUBJECTS SA M Address Fax: No (404)329-7700 Yes Human Subjects Assurance No. IRB Status: IRB Date: Address Tel: Fax: E-MAIL ADDRESS VERTEBRATE ANIMALS Animal welfare assurance no. No Yes IACUC Status: IACUC Date: ASSURANCE OF THOSE SIGNING THIS APPLICATION: I certify that the statements in this Application that pertain to me and my Institution are true, complete, and accurate to the best of my knowledge, and that I have provided all information required by this Application. I am aware that false, fictitious, or fraudulent statements or claims may result in criminal, civil, or administrative penalties. I agree that I will (and the Signing Official further represents that the institution will) comply with all Grant Policies of the Society, including reporting requirements, to the extent applicable. I understand that a failure to comply with such Policies, or the the terms of the Application, or any additional terms associated with a Grant, may result in the Society suspending or cancelling Grant funding, to be decided by the Society at its sole discretion. The Applicant certifies, and the Signing Official certifies that the Institution has verified, that the Applicant is a citizen or permanent resident of the United States of America. SIGNATURE OF APPLICANT (In ink. "Per" signature not acceptable) . DATE SIGNATURE OF DEPARTMENT HEAD (In ink. "Per" signature not acceptable) DATE SIGNATURE OF SIGNGING OFFICIAL (In ink. "Per" signature not acceptable) DATE Applicant: Application Contacts Role Role Name Name Institution Institution Title Title Division Division Dept Dept Address Address Tel: Fax: Tel: E-mail Role Role Name Name Institution Fax: E-mail Institution Title Division Division Dept Dept Address Address Fax: Name Institution Title Division Dept Address Tel: SA Role Tel: Fax: E-mail M E-mail PL Tel: E Title Fax: Role Name Institution Title Division Dept Address Tel: E-mail E-mail Role Role Name Name Institution Institution Title Title Division Division Dept Dept Address Fax: Address Tel: E-mail Fax: Tel: E-mail Fax: GENERAL AUDIENCE SUMMARY APPLICANT NAME DATE SUBMITTED TITLE OF PROJECT (Titles exceeding 81 characters, including spaces and punctuation, will be truncated.) Physician Training Award in Cancer Prevention This General Audience Summary will become public information; therefore, do not include proprietary/confidential information. The ACGME accredited residency program in general preventive medicine and public health at the School of Medicine will provide physician training in cancer prevention and control through a well-defined and enriched curriculum track for resident awardees, featuring a variety of cancer prevention control research and practice experiences and related academic coursework. The training is designed to develop board certified preventive medicine specialists who will be future leaders in research, education and interventions in cancer prevention and control and will contribute to the accomplishment of national and ACS objectives for cancer control. SA M PL E The Department of Preventive Medicine at the School of Medicine has several NIH-supported research projects in cancer prevention and control and operates related clinical services for hospital employees and other occupational populations. The training program is building upon this rich resource in cancer control research and service, as well as on its longstanding affiliations with health departments, hospitals and other practicum training sites with experience and programs in cancer prevention and control. Principal Investigator: [Click here and type last name, first name] 1.1 TABLE OF CONTENTS Cover Pages – (Signature Page, Contact Page, General Audience Summary) Table of Contents ............................................................................................................................... 1.1 Reply To Previous Review (Resubmitted Applications Only)..................................................... 2.1 Previous Critiques (resubmissions only) Institution Information ................................................................................................................. 3.1 Residency Program Information ................................................................................................ 4.1 Biographical Sketch of Principal Investigator ............................................................................. 5.1 E Biographical Sketches of Key Faculty ........................................................................................ 6.1 Program Goals And Description................................................................................................. 7.1 Required Letters Appendix: SA M ACGME accreditation letter Copies of resident final reports Copies of resident schedules PL Budget and Justification of Budget ............................................................................................ 8.1 Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 2.1 SA M PL E REPLY TO PREVIOUS REVIEW (FOR RESUBMISSIONS ONLY) Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 3.1 SA M PL E INSTITUTION INFORMATION Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 4.1 RESIDENCY PROGRAM INFORMATION 1. Provide the following information about the residency program's most recent accreditation by the Accreditation Council for Graduate Medical Education. Include in the appendix a copy of the letter of accreditation. If the program was cited by the ACGME, any issues/concerns raised must be addressed in item 4 below and a copy of the progress report attached. Date of accreditation: Accreditation Status Effective period: Full: Provisional: Probation: 2. For which phases of residency training in preventive medicine is the program approved? Indicate by providing number of approved resident positions. Academic: 3. Number of residents in: PGY2: PGY3: PGY4: PGY5: PL PGY1: Practicum: E Clinical: SA M 4. Describe the residency program; beginning with relevant historical background such as the length of the program’s accreditation, any statement of mission or training emphasis, the career paths of former residents, etc. Complete the attached table regarding program graduates, indicating with an asterisk those that were supported with American Cancer Society funding. Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 4.2 TABLE OF PTACP RESIDENCY PROGRAM GRADUATES Date of ABPM Certification Current (or last known) Position, Institution and Location Describe cancer prevention and control activities, if not obvious by position title. SA M PL E Resident Name Date Began/Date Graduated Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 4.3 TABLE OF ALL RESIDENCY PROGRAM GRADUATES Date of ABPM Certification Current (or last known) Position, Institution and Location Document any cancer relevance, if not obvious by position title. SA M PL E Resident Name Date Began/Date Graduated Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 5.1 BIOGRAPHICAL SKETCH Provide the following information for the Principal Investigator and Key Faculty Follow this format for each person. DO NOT EXCEED TWO PAGES. NAME POSITION TITLE EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.) DEGREE (if applicable) INSTITUTION AND LOCATION YEAR(s) FIELD OF STUDY PL E A. Certifications SA M B. Current Activities and Previous Positions C. Professional Society Memberships and Service Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 5.2 D. Academic/Professional Honor Societies, Consultantships, Appointed or Elected SA M PL E E. Representative Publications (identify with an asterisk any publications on cancer prevention and control) Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 7.1 SA M PL E PROGRAM GOALS AND DESCRIPTION Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 8.1 BUDGET Year 1 Year 2 Year 3 Year 4 Year 5 (6 months) Trainee Expenses Resident Stipends (salary and fringe benefits) Tuition and Fees Trainee Travel Other (describe) M Category Total Permanent Equipment (Itemize) PL Staff Travel Other (describe) Category Total Subcontracts (Categorize on continuation page) E Non-trainee Expenses Personnel [Itemize all positions: include names of personnel, percent effort, and compensation (salary & fringe benefits)] SA Category Total Supplies (Group into major categories) Category Total Miscellaneous (List specific amounts for each item) Category Total Direct Costs Total No indirect costs allowed. See Policies. Annual Total Total Amount Requested Physician Training Award in Cancer Prevention Application American Cancer Society January 2014 Principal Investigator: [Click here and type last name, first name] 8.2 SA M PL E JUSTIFICATION OF BUDGET Physician Training Award in Cancer Prevention Application American Cancer Society January 2014