CHLA Core Pilot Program Application

Your Information

First Name

Last Name

Division

Department

Phone Number

Applicant Affiliation/Title

If applicant is not faculty, list Faculty PI name who is co-investigating pilot project

Core Information

Core Name

Core Director Name

Have you met with Core Director to discuss the project

Yes

Have you consulted with the Biostatistics Core to ensure the proposed pilot will capture the best data for planned proposals?

Yes

If not, we encourage a complimentary meeting. Please connect with Ramon Durazo-Arvizu, PhD, Faculty Director, Lilith Moss, PhD, Sr. Biostatistician; and/or Amy Chai, PhD, Biostatistician.

Your Proposed Pilot Project

Project Title

Project Start Date

Project End Date

Project Abstract (2-3 lines)

Specific Aims and Statement of Scientific Significance of Overall Pilot Research (300 words)

Rationale for Requesting Support for the Pilot Project, including how data is essential for Planned Research (100 words)

Pilot Study Design, including proposed assessments and measures (600 words)

Does pilot study require IRB or IACUC approval

Yes

If yes, please list the protocol #

Please describe the plan and timeline to submit an extramural application, including applicant organization, PA or RFA, for supporting the proposed overall research pilot program (100 words)

Please list prior pilot project funding over the last 3 years and outcomes in terms of extramural grant support

Please attach any supporting documents

Please attach any supporting documents

Supporting Document

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx, xls, xlsx.

Your Proposed Pilot Project Budget

Budget Justification, including summary of core-rendered services and volume

Total Overall Budget

If expenses exceed the approved pilot budget, list below the PeopleSoft Project ID or cost center that will be charged as the funding resource.

PI Responsibility Text

Applicant acknowledges that it is the responsibility of the awarded PI to ensure the pilot project stays within the budget. Any expenses over the approved budget must be covered by the PI’s additional funding resource and is not the responsibility of the participating Core or Research Operations.*

I Acknowledge

Applicant confirms that if there are non-core portions required to complete the pilot study, funding resources are available

Yes

N/A

If non-core portions are required, list below the PeopleSoft Project ID or cost center that will be used as the funding resource

Applicant agrees to notify the Core Director of any extramural funding and/or peer-reviewed publication(s) resulting from pilot project

I Agree

Please attach any supporting documents

Please attach any supporting documents

Supporting Document

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx, xls, xlsx.

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