2020 Tufts CTSI CTRC Sample Processing during COVID-19 Voucher Program

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2020 Tufts CTSI Sample Processing during COVID-19 Request Form

Applications will be accepted on a rolling basis until further notice.

Award year

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Please download the document template required for your submission. You will be prompted to upload your completed document as part of your application.

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CERTIFICATION AND AUTHORIZATION FORM: Only one certification and authorization form is required per application.

Attachment:2020 Tufts CTSI CTRC Voucher Program Certification and Authorization Form.docx

CERTIFICATION AND AUTHORIZATION FORM:

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Upload file

Document download section end

Title or position

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First name

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Last name

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Degree(s)

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DDS DMD DNP DVM EdD MA MD MHS MMSc MPAS MPH MS MSN PhD Other

Degree(s), other

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Primary affiliation

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School or center

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School or center, other

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Department

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Academic rank
Please specify your academic rank, if applicable.

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Academic rank, other

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Email address
Please provide email address associated with your primary affiliation.

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Phone number
Please provide phone number associated with your primary affiliation.

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Is there an additional study contact on this project?

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Yes No

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STUDY CONTACT INFORMATION

Study contact's first name

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Study contact's last name

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Study contact's email address

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RESEARCH ADMINISTRATOR INFORMATION

Research Administrator's first name

Research Administrator's last name

Research Administrator's email address

Collaborator information section end

Project title

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Project description
Please provide an abstract or brief description of your project (500 words or less)

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Funding agency(ies)

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Federal

Foundation

Tufts Internal

Other

Funding agency(ies), federal

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National Institutes of Health

Patient-Centered Outcomes Research Institute

National Science Foundation

Department of Defense

Centers for Disease Control and Prevention

Centers for Medicare and Medicaid Services

Food and Drug Administration

Agency for Healthcare Research and Quality

Funding agency(ies), foundation

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Funding agency(ies), industry

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Funding agency(ies), other

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Study start date

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Study projected end date

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SAMPLE PROCESSING INFORMATION

What kind of human source material(s) are the samples?

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Blood Urine Other

Sample Type, other

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Approximately how many more samples need processing?

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Prior to COVID-19, where were samples being processed and by whom?

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Sample processing protocol
Please provide a brief description of your processing protocol (500 words or less) or use the document upload below.

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You may upload a streamlined version of the protocol here instead of using the text box above (if so, please enter "n/a" in the field above.)

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Project information section end

APPLICANT CERTIFICATION AND AUTHORIZATION

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I, (as PI), certify that the statements herein are true, complete, and accurate to the best of my knowledge. If a CTRC voucher is awarded, I agree to accept responsibility for scientific conduct of the project, provide the required progress and outcomes reports, and comply with the Tufts CTSI terms and conditions outlined in the request for applications. I also accept responsibility for payment of any and all over-expenditures should they occur as a result of this project.

Citation requirements:
Any publication, poster, or presentation resulting from this research project will cite the Tufts CTSI award UL1TR002544 and comply with the NIH Public Access Policy.

Long-term Outcomes Tracking:
Awardees are required to report study progress and outcomes annually using a Tufts CTSI-provided online tool for at least five (5) years after the funding ends. Outcomes to be reported include professional presentations, published manuscripts, subsequent funding applications and awards, research products and associated intellectual property protections, and activities to implement findings into clinical care or public health.

Principal investigator's signature

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Principal investigator's signature date

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M-D-Y

Please review your information prior to final submission. If you are satisfied with your responses, please click "SUBMIT". You will have a chance to provide your email address to receive a confirmation email.

If you would like to save your progress and return to where you left off to complete the application later (before the submission deadline), please click "SAVE AND RETURN LATER." Please provide your email address when prompted and save the return code that will be shown on the screen. You will receive an email with a link to return to your application, but the email will NOT contain the return code. Please note that if you lose or forget your return code, DO NOT click on the "Start Over" button, as this will erase all of your data. Instead, please email voucher@tuftsctsi.org and we will help you return to your unfinished application.

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Application status

Total budget

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