Fillable Printable VA Form 10-1313-1
Fillable Printable VA Form 10-1313-1
VA Form 10-1313-1
MERIT REVIEW APPLICATION
1. LAB NO.2. APPLICATION NO.3. REVlEW GROUP4. REVIEW DATE5. FACILITY NO.
6. LOCATION HEALTH CARE FACILITY (VAMC, OPC, CITY, STATE)
7. SOCIAL SECURITY NO.
8. DATE OF LAST SUBMISSION-
MR
9. PRINCIPAL INVESTIGATOR(S) (Last Name, First Name, M.i. ) DEGREE TELEPHONE NUMBERS(S)
10. PROGRAM TITLE (72 Characters maximum)
11. AMOUNT REQUESTED EACH YEAR
1ST 2ND3RD4TH5THTOTAL
12. VA EMPLOYMENT STATUS
WOC ____HRS. WEEK
ATTENDING ____HRS./WEEK
CONSULTIN ____ HRS./WEEK
PART TIME ( /8 TIME)
FULL TIME
13. VA SALARY SOURCE
RESEARCH CC 103
RESEARCH CC 104
RESEARCH CC 105
RESEARCH CC 110
CAREER DEVELOPMENT CC 108
PATIENT CARE
HSR&D
RR&D
OTHER VA
15. PROGRAMCOST CENTER
16. PRIMARY RESEARCH PROGRAM AREAPRIMARY RESEARCH SPECIALTY AREA
17. VA HOSPITAL SERVICE AND SECTION
18. ACADEMIC RANK, DEPARTMENT AND AFFILIATION
19. PROGRAM USE (Each Item must have a response)
YESHUMAN SUBJECTSNOYESINVESTIGATIONAL DRUGSNOYESRADIOISOTOPENO
YESANIMAL SUBJECTSNOYESINVESTIGATIONAL DEVICESNOYESBIOHAZARDSNO
20. SUMMARY OF RESEARCH/ DEVELOPMENT SUPPORT FOR THREE PRIOR
TOTAL VATOTAL NON-VAGRAND TOTAL
FY
F
FY
21.DATE ENTERED ON DUTY VA, OR EXPECTED DATE OF ENTRY VA
SIGNATURE PRINCIPAL INVESTIGATOR(S)
SIGNATURE ACOS FOR RESEARCH AND DEVELOPMENT
Date
Page 1 of VA Form 10-1313 package
Date
VA FORM
DEC 2006
10-1313-1
