JHU School of Nursing
Intent to Submit a Proposal

(Completed by Principal Investigator, Submit to the Center for Collaborative Intervention Research)

Note: Once the form is submitted, a copy of the completed form will be available for printing.

PI First Name:
PI Last Name:
PI Credentials:
Phone:
Fax:
Funding Agency:
Proposal Type (e.g. R01, R03):

Proposal Due Date (for CCIR Review):

Are you responding to an RFA/RFP? YesNo
Web Address:

Project dates covered by proposal (1 year):

Title of project:  
Note: NIH guidelines are 56 characters or less

NOTE: Your proposal will be reviewed during the standing Scientific Review             Committee (SRC) meeting to be held within 2 weeks of proposal submission.  Additional SRC meetings             will be scheduled as needed.

OPTIONAL: For proposals seeking external funding, you are encouraged to use an             external reviewer to either participate in the SRC meeting or review the proposal independently. The PI is responsible for initial contact and confirming external reviewer participation prior to             submitting this document to the Center. The Center will send a copy of the proposal and review form             to the chosen external reviewer reviewing independently. As well, the Center will also arrange for             compensation for external independent reviews only (non-JHU faculty member). Please list external             reviewer(s) to be contacted (please list 3 possible choices).

	Name, Credentials and Institutional Affiliation	Area of Expertise	Adress, Phone #, Email
1st
	Attending SRC Meeting Reviewing Independently
2nd
	Attending SRC Meeting Reviewing Independently
3rd
	Attending SRC Meeting Reviewing Independently

Consultation Services
1. Do you need to consult with Center faculty regarding this proposal?  

YesNo

Personnel
1. PI % of Effort (In Kind): .             Will effort be fully compensated if awarded?  

YesNo

2. Do you anticipate any need to discuss a modification of SON roles or responsibilities?  

YesNo

3. Other SON Faculty, Senior Staff or Support Staff to be named on this proposal (Please include name, credentials, institutional affiliation, area of expertise and contact information):
512 characters max

4. Do you anticipate any need to discuss a modification of their SON roles and responsibilities?  

YesNo