Research Committee

Project Funding Re-Application

Contact the Director of Fiscal Affairs prior to completing this form to ensure additional funds that are being requested are within the per project caps established by internal policy. “Re-Applications” will compete with new proposal requests and undergo review by the Committee at a convened meeting. This form does not need to be completed for one time requests of up to $5,000 to the Director of Medical Research.

SP Code:	Original Approval Date:

Title of Project:

Principal Investigator:

Medical Staff Physician/Clinician

Research Scientist

Medical/Surgical Resident

Other (identify)

Routing Location:	E-mail:

Name of Person Completing Application:

SECTION 1

Original Research Goal:

Has there been any change in the original goal of the project?

No

Yes If “Yes,” please explain.

Attach the original timeline submitted with your application. Please provide a concise summary of study progress since the last review by the Research Committee.

Will the project be completed within the originally proposed timeline?
Yes

No	If “No,” attach a revised timeline, explain any major deviations, unexpected problems or extenuating circumstances and the measures you have taken to correct them.

SECTION 2

Indicate the amount of funds remaining in your project. $ as of (date).

Are any remaining funds sufficient to complete the project as proposed?
Yes

No	If “No,” contact the Office of Scientific Writing & Publications or Sponsored Programs for advice on obtaining additional funds and describe your preliminary plans to obtain funds.

Have you applied for and/or received additional funding for this project?
No
Yes If “Yes,” complete A or B below:

A.	If your funding request is pending, please provide funding information:

Source
Amount
Anticipated Funding Decision Date

If funds have been received, please provide funding information:

Source
Amount

Additional funds being requested: $

Please provide an itemized budget, including justification and sufficient detail on each item to determine how you arrived at the requested figure.

Please provide an explanation of the need for the additional funds, including an explanation of why funds originally approved were not sufficient to complete the study.

STATEMENT

I certify that statements herein and attached are true and complete to the best of my knowledge.

____________________________________

Signature of Principal Investigator	Date

Please check all that apply and attach to report:

Original project timeline

Revised project timeline, if applicable

Revised protocol, if applicable

Any resulting abstracts, manuscripts or publications

Submit completed paperwork to: Patti Baer, Research Committee Administrator - 1R3

Version – December 28, 2015

Research Committee –Project Funding Re-Application	Page 2 of 2

MARSHFIELD MEDICAL RESEARCH & EDUCATION FOUNDATION

Baer, Patricia E

2016-07-13

Knecht, Justin E

Marshfield Clinic