Fillable Printable VA Form 10-1313-10
Fillable Printable VA Form 10-1313-10
VA Form 10-1313-10
RESEARCH ADVISORY GROUP SUMMARY STATEMENT
4. LOCATION HEALTH CARE FACILITY (VAMC, OPC, City, State)1. REVlEW DATE 2. REVIEW GROUP (Leave blank) 3. FACILITY NO.
5. SOCIAL SECURITY NO. 6. DATE OF LAST RAG REVIEW
(If a resubmission)
TELEPHONE NO.DEGREE7. PRINCIPAL INVESTIGATOR (Last Name, First Name, Ml)
2ND
$
8. PROGRAM TITLE (72 characters maximum)
9. AMOUNT REQUESTED EACH YEAR
1ST
11. VA SALARY SOURCE10. VA EMPLOYMENT STATUS
RESEARCH CC 103
HSR/D
FULL TIME
12. DATE ENTERED ON DUTY VA:
RR&D
PART TIME ( /8 TIME)
RESEARCH CC105
CONSULTING
HRS./WEEK CAREER DEVELOPMENT CC108
OTHER VA
ATTENDIN HRS./WEEK
PATIENT CARE
WOC
HRS./WEEK
13. PROGRAM COST CENTER
PRIMARY RESEARCH SPECIALTY AREA14 PRIMARY RESEARCH PROGRAM AREA
15. VA HOSPITAL SERVICE AND SECTION
16. ACADEMIC RANK, DEPARTMENT AND AFFILIATION
17. PROGRAM USE (Each item must have a response)
RADIOISOTOPEHUMAN SUBJECTS NOINVESTIGATIONAL DRUGS NO
YES
NO
YES
NO
INVESTIGATIONAL DEVICES YES
ANIMAL SUBJECTS NO BIOHAZARDS
NO
YES
DO NOT WRITE IN THESE SPACES
RECOMMENDATION PRIORITY SCORE DURATION FUNDING START DATE
RECOMMENDED FUNDS 1ST YEAR 2ND YEAR TOTAL
RECURRING
$
$ $
NONRECURRING
$
$
SIGNATURE PRINCIPAL INVESTIGATOR DATE
SIGNATURE ACOS FOR RESEARCH AND DEVELOPMENT DATE
10-1313-10
VA FORM
JUN 1990
EXPECTED DATE
MERIT REVIEW:
YES
YES
Page 10 of VA Form 10-1313 package
