Date Submitted: Proposal Type: If renewal, current grant: Resubmission? Comm Code:

Grant Application

1st or 2nd: TITLE OF PROJECT (Titles exceeding 81 characters, including spaces and punctuation, will be truncated.)

APPLICANT NAME HIGHEST DEGREE(S)

POSITION TITLE: ACADEMIC RANK:

APPLICANT’S CURRENT INSTITUTION

DIVISION:

DEPARTMENT:

E-MAIL ADDRESS:

Tel: Fax:

MAILING ADDRESS (Street, city, state, postal code, country)

PROGRAM ELIGIBILITY INFORMATION: (Responses to selected fields displayed below. For some grant programs this section may be blank.)

DATES OF PROPOSED PROJECT (MM/DD/YYYY) PROPOSED BUDGET ( ( From Through

SIGNING OFFICIAL FOR Name Name

Title Address

Address

Tel: Fax: Tel: Fax:

EIN E-MAIL ADDRESS

DUNS HUMAN SUBJECTS No Yes VERTEBRATE ANIMALS No Yes Human Subjects Assurance No.

IRB Status: IRB Date:

Animal welfare assurance no.

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 legally eligible to work in the United States of America for the period of the award. SIGNATURE OF APPLICANT DATE SIGNATURE OF DEPARTMENT HEAD DATE

. SIGNATURE OF SIGNING OFFICIAL DATE

Applicant: Application Contacts Role Role

Name Name

Institution Institution Title Title

Division Division Dept Dept Address

Address

Tel: Fax: Tel: Fax:

E-mail E-mail Role Role

Name Name

Institution Institution Title Title

Division Division Dept Dept Address

Address

Tel: Fax: Tel: Fax:

E-mail E-mail Role Role

Name Name

Institution Institution Title Title

Division Division Dept Dept Address

Address

Tel: Fax: Tel: Fax:

E-mail E-mail Role Role

Name Name

Institution Institution Title Title

Division Division Dept Dept Address

Address

Tel: Fax: Tel: Fax:

E-mail E-mail

GENERAL AUDIENCE SUMMARY APPLICANT NAME DATE SUBMITTED

TITLE OF PROJECT (Titles exceeding 81 characters, including spaces and punctuation, will be truncated.)

This General Audience Summary will become public information; therefore, do not include proprietary/confidential information.

Principal Investigator: [Click here and type last name, first name] 1.1

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

TABLE OF CONTENTS

Cover Pages – (Signature Page, Contact Page, General Audience Summary)

Table of Contents ............................................................................................................................... 1.1

Reply To Previous Review (Resubmitted and Renewal Applications) ....................................... 2.1

Previous Critiques (Resubmitted and Renewal Applications)

Institution Information ................................................................................................................. 3.1

Residency Program Information ................................................................................................ 4.1

Biographical Sketch of Principal Investigator ............................................................................. 5.1

Biographical Sketches of Key Faculty ........................................................................................ 6.1

Program Goals And Description................................................................................................. 7.1

Budget and Justification of Budget ............................................................................................ 8.1

Required Letters

Appendix:

ACGME accreditation letter Copies of resident final reports Copies of resident schedules

Principal Investigator: [Click here and type last name, first name] 2.1

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

REPLY TO PREVIOUS REVIEW (RESUBMITTED AND RENEWAL APPLICATIONS)

Principal Investigator: [Click here and type last name, first name] 3.1

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

INSTITUTION INFORMATION

Principal Investigator: [Click here and type last name, first name] 4.1

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

RESIDENCY PROGRAM INFORMATION (See PTACP Instructions for items 5-7.) 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, address in item 4 below any issues or concerns raised and attach a copy of the progress report.

Date of accreditation: Effective period:

Accreditation Status Full: Provisional: Probation:

2. For how many total resident positions is the program accredited by ACGME?

Provide the number of residents in each year, i.e., how many approved positions are filled:

3. The residency program (check all that apply in first column):

Accepts residents with only PGY1 training.

Accepts only residents with other board certification.

Is a combined program (e.g., with internal medicine, family medicine, etc.).

4. Describe the residency program. Begin 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. If there have been significant recent changes in the context of the residency in which this training program resides, such as a transition in program leadership, change in affiliation agreements, etc., describe them.

PM1: PM2:

Principal Investigator: [Click here and type last name, first name] 4.__

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

Grant Period (1/1/__ - 6/30/__)

Resident Name Date Began/Date Graduated

Date of ABPM Certification

Current (or last known) Position, Institution, and Location

Describe cancer prevention and control activities, if not evident in position title.

TABLE OF PTACP RESIDENCY PROGRAM GRADUATES (list in chronological order, starting with most recent)

Principal Investigator: [Click here and type last name, first name] 4.__

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

Resident Name Date Began/Date Graduated

Date of ABPM Certification

Current (or last known) Position, Institution and Location

Describe cancer prevention and control activities, if not evident in position title.

TABLE OF ALL RESIDENCY PROGRAM GRADUATES (list in chronological order, starting with most recent)

Principal Investigator: [Click here and type last name, first name] 5.1

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

BIOGRAPHICAL SKETCH Provide the following information for the Principal Investigator and Key Faculty

Follow this format for each person. DO NOT EXCEED TWO PAGES FOR EACH SKETCH.

NAME

POSITION TITLE

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)

INSTITUTION AND LOCATION DEGREE

(if applicable) YEAR(S) FIELD OF STUDY

A. Certifications B. Current Activities and Previous Positions C. Professional Society Memberships and Service

Principal Investigator: [Click here and type last name, first name] 5.2

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

D. Academic/Professional Honor Societies, Consultantships, Appointed or Elected E. Representative Publications (identify with an asterisk any publications on cancer prevention and control)

Principal Investigator: [Click here and type last name, first name] 6.1

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

BIOGRAPHICAL SKETCH Provide the following information for the Principal Investigator and Key Faculty

Follow this format for each person. DO NOT EXCEED TWO PAGES FOR EACH SKETCH.

NAME

POSITION TITLE

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)

INSTITUTION AND LOCATION DEGREE

(if applicable) YEAR(S) FIELD OF STUDY

A. Certifications B. Current Activities and Previous Positions C. Professional Society Memberships and Service

Principal Investigator: [Click here and type last name, first name] 6.2

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

D. Academic/Professional Honor Societies, Consultantships, Appointed or Elected E. Representative Publications (identify with an asterisk any publications on cancer prevention and control)

Principal Investigator: [Click here and type last name, first name] 7.1

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

PROGRAM GOALS AND DESCRIPTION

Principal Investigator: [Click here and type last name, first name] 8.1

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

REQUESTED 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) Non-trainee Expenses Personnel [Itemize all positions: include names of personnel, percent effort, and compensation (salary & fringe benefits)]

Staff Travel Other (describe) Category Total Subcontracts (Categorize on continuation page)

Category Total Permanent Equipment (Itemize) 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

Principal Investigator: [Click here and type last name, first name] 8.2

Physician Training Award in Cancer Prevention American Cancer Society Application January 2020

Overall Residency Program Budget

SOURCE OF FUNDING (identify each at right – include any pending)

TOTAL

PMR core faculty & staff (salary and fringe)

- Residency director (___%) - Key faculty #1 (___%) - Key faculty #2 (___%) Residents (FTE salaries and fringe)

Travel Supplies Tuition (2 residents/year)

Other (describe)

TOTAL

JUSTIFICATION OF BUDGET (Use continuation pages as needed.)