Fillable Printable VA Form 10-1436
Fillable Printable VA Form 10-1436
VA Form 10-1436
RESEARCH AND DEVELOPMENT INFORMATION SYSTEM
PROJECT DATA SHEET
CONTROL NUMBER
(Leave blank)
1. HEALTH CARE
FACILITY NO.
4. SOCIAL SECURITY NO.
2. LOCATION (City, State)
3. PRINCIPAL INVESTIGATOR (Last, First, M.I., Degree)
5. STATUS IN PROJECT6. PROJECT NUMBER
7. TYPE OF REPORT
01 AWARDEE (Recipient of Award)
INITIAL
FINAL
PROGRES
02 NOT AWARDEE, BUT RESPONSIBLE VA
INVESTIGATOR
8. PROJECT TlTLE (Do Not Exceed 142 Spaces)
9. HAS PROJECT TITLE CHANGED SINCE LAST REPORT?
NO
YES
10. CO-PRINCIPAL INVESTIGATOR(S) NAME, DEGREE(S) AND SOCIAL SECURITY NO. (Maximum of 2)
1.
2.
FUNDING CODE
_ _ _ _ - _ _ - _ _ _ _ _ _
11. FUNDING AND ADMINISTRATION (See codes on instruction sheets)
ADMIN. CODE
NAME IF "OTHER"
1.
2.
3.
12. PROJECT USES (Each item must have a response)
NO
HUMAN SUBJECTSYESNO
YES
NO
RADIOISOTOPES
YES
INVESTIGATIONAL
INVESTIGATIONAL DEVICES
NO
BIOHAZARDSYE
YES
NO
ANIMAL SUBJECTS
NO
YES
13. RESEARCH FOCUS: (Mark yes only if the major reason for the research project is to study the particular topic)
NOYES
FEMALESYESNOAGENT ORANGE (DIOXIN)
PRISONERS OF WAR
YES
NO
14. KEYWORDS (MeSH terms only; minimum three, specify up to eight)
1.
5.
2.
6.
3.
7.
8.
4.
15. ABSTRACT (Enter on reverse)
16. SIGNATURE OF PRINCIPAL INVESTIGATOR
17. DATE
EXISTING STOCKS OF VA FORM 10-1436, MAY 1985,
WILL NOT BE USED
_ _ _ _ - _ _ - _ _ _ _ _ _
10-1436
VAFORM
JUN 1989
PAGE 1
Abstract: Organize under the following headings: (a) objective of the project; (b) research plan; (c) methodology,
and (d) findings, results or conclusions reached to date. Limit to 500 words.
VAFORM
JUN 1989
Page 2
10-1436
INSTRUCTIONS FOR COMPLETING VA FORM 10-1436 - PROJECT DATA SHEET
GENERAL:
AProjectDataSheet(VAForm10-1436)isrequired(M-3,PartI,Change4)forresearchinvolvingVA
facilities,resources,employees,orpatients.AninitialProjectDataSheetmustbesubmittedwithin15days
after the initiation of the project. A Progress report must be submitted annually thereafter.
Iftheprincipalinvestigator(orco-principalinvestigator)hasnotcompletedanInvestigatorDataSheet(Page
18-VAForm10-5368)atthismedicalcenter,acompletedInvestigatorDataSheetmustbereturnedwiththis
Project Data Sheet.
ProjectsfundedbyCooperativeStudiesarereportedonlybytheStudyChairperson.HSR&DFieldPrograms
arereportedonlybytheHSR&DFieldProgramDirector.Forprojectswithco-principalinvestigator(s),submit
onlyoneProjectDataSheet,arbitrarilydesignatingoneco-principalinvestigatorasprincipalinvestigator
responsible for completing the Project Data Sheet. Report the remaining co-principal investigator(s) in item 10.
SPECIFIC ITEMS:
Principal/Co-PrincipalInvestigator--AllPrincipalInvestigators(andCo-PrincipalInvestigators)
musthaveaVAappointment.IfthePrincipalInvestigatoroftheprojectdoesnothaveaVA
appointment,butifaportionoftheprojectistobedoneattheVAbyaVAinvestigator,enter
theVAinvestigatorasthePrincipalInvestigatorandcodeitem5(below)as"02".Onlyone
name is to be entered in this space.
Item 3:
Item 5:
StatusofPIinProject--Mark"02"onlyifyouarenottherecipientofthegrantorawardornot
the initiator of the project.
Item 6:
Project Number--Each project must have a 4 digit project number.
Item 8:
Project Title--Do not exceed 142 spaces.
ProjectTitleChange--Iftheprojecttitlehaschangedsincelastreport,mark"YES."Atitle
change is permissible ONLY if there is NOT a change in funding source(s) (see item 12).
Item 9:
Item 10:InthecaseofCo-PrincipalInvestigators,listoneasPrincipalInvestigatorinitem1.Donot
enter the names of Co-Investigators or anyone who does not have a VA appointment.
Item 11:
FundingandAdministration--FundingandAdministrativecodesareonthebackofthispage.It
ispossibletodesignateuptothreefundingsourcesandadministrativecodesforasingle
project.DoNOT,however,useagenerictitleforyourresearchprojectsanddesignatemultiple
funding sources for your overall effort. Keep projects separate.
Item 14:KeywordsarecheckedagainsttheMedicalSubjectHeading(MeSH)indexwhichismaintained
bytheNationalLibraryofMedicine.AlistofthesetermsislocatedintheResearchOfficeor
the VA library.
Item 15:
ProjectAbstract--Organizeabstractunderthefollowingheadings:(a)objectiveoftheproject;
(b)researchplan;(c)methodology,and(d)findings,resultsorconclusionsreachedtodate.
Limit to 500 words.
VAFORM
JUN 1989
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FUNDINGSOURCECODES
[03]=DeptofDefense[15]=FoodandDrugAdmin[27]=NatlScienceFoundation
[05]=DeptofEducation[17]=HealthResources&SvcsAdmin[29]=RehabilitationSvcsAdmin
[07]=DeptofEnergy[19]=NatlInstofOccupationalSafety[35]=U.S.PublicHealthService
[09]=DeptofHealth&HumanServices[21]=NatlAeronautics&SpaceAdmin[99]=Other(SpecifyName)
[11]=DeptofLabor[23]=NatlCenterforHealthSvcsRsch
[13] = Environmental Protection Agency [25] = Natl Library of Medicine
[03]=NatlCancerInstitute[23]=NatlInstofNursing
[05]=NatlEyeInstitute[25]=NatlInstonAging
[07]=NatlHeart,Lung,&BloodInstitute[27]=NatlInstonAlcoholAbuseandAlcoholism
[09]=NatlInstofAllergyandInfectiousDisease[29]=NatlInstonArthritis
[11]=NatlInstofChildHealth&HumanDevelopment[31]=NatlInstonDeafness&OtherCommonDisorders
[13]=NatlInstofDentalResearch[33]=NatlInstonDrugAbuse
[15]=NatlInstofDiabetes,Digestive&KidneyDisease[35]=NatlInstonMentalHealth
[17]=NatlInstofEnvironmentalHealthSciences[37]=DivisionofResearchResources
[19]=NatlInstofGeneralMedicalSciences[43]=NIH-Institutenotknownatpresent
[21] = Natl Inst of Neurological & Communicative Disorders
[01]=AffiliatedUniversity[05]=LocalGovernment[09]=ForeignGovernment
[03]=PrivateDonor[06]=StateGovernment[99]=Other(SpecifyName)
[01]=A.H.Robbins[29]=E.R.Squibb[54]=Marion[79]=Rorer
[03]=Abbott[31]=EliLilly[56]=McNeil[81]=Ross
[05]=Adria[33]=G.D.Searle[58]=MeadJohnson[83]=Sandoz
[07]=AlphaTherapeutic[34]=G.H.Besselaar[60]=MerckSharpe&Dohme[84]=Schering
[08]=AmericanCyanamid[36]=Genetech[62]=Merrell-Dow[85]=SmithKline
[09]=Ayerst[38]=Glaxo[64]=Miles[87]=Sterling-Winthrop
[11]=Beecham[40]=Hoechst-Roussei[66]=NorwichEaton[89]=Stuart
[13]=BoehringerIngelheim[42]=Hoffman-LaRouche[68]=Organon[91]=Syntex
[15]=Boots[44]=Hybritech[70]=Ortho[93]=Upjohn
[17]=Bristol-Meyers[46]=Janssen[73]=Parke-Davis[95]=Warner-Lambert
[19]=BurroughsWellcome[48]=Knoll[75]=Pfizer[97]=Wyeth
[21]=Ciba-Geigy[50]=Lederle[76]=PurdueFrederick[99]=Other(SpecifyName)
[25]=Dupont[52]=Lorex[78]=Roche
2.NationalInstitutesofHealth(Enter"91"followedbyItemCode:eg,NationalEyeInstitute=9105)
[02]=ResearchAdvisoryGroup(Prog821;CC103)[09]=OtherDesignatedResearch(Prog821;CC109
[03]=MeritReview(Prog821;CC103)[22]=RehabilitationR&D(Prog822)
[06]=SpecialResearchInitiatives(Prog821;CC106)[23]=AgentOrangeandRelatedHerbicides(Prog823)
[07]=CooperativeStudies(Prog821;CC107)[24]=HealthServicesR&D(Prog824)
[08] = Career Development (Prog 821; CC 108)
[01]=NoFunding(FundingCodeis"0000")[05]=DVA-GeneralPostFunds
[02]=DVAfunds(FundingCodebeginswith"90")[06]=DVA-PrivateResearchCorporation
[03]=DVA-ReimbursedfromanotherFederalAgency[07]=AffiliatedUniversity
[04]=DVA-Directgrant[08]=OtherAgency
3.OtherFederalGovernmentAgency(Enter"92"followedbyItemCode:eg,DepartmentofEnergy=9207)
4.AcademicInstitution,PrivateDonor,orOtherGovernment(Enter"93"followedbyItemCode)
5.PrivateProprietaryCompany(Enter"97"followedbyItemCode:eg,EliLilly=9731)
6.VoluntaryAgencyorFoundation(Enter"98"followedbyItemCode:eg,MarchofDimes=9855)
7.None(Enter0000)
ADMINISTRATIVECODES
VAFORM
JUN 1989
1.DepartmentofVeteransAffairs(Enter"90"followedbyItemCode:eg,CareerDevelopment=9008)
[03]=Alzheimer’sDis&RelatedDisAssoc[27]=CouncilforTobaccoResearch[63]=NationalDairyCouncil
[05]=AmericanCancerSociety[31]=CysticFibrosisFoundation[67]=NatlFndnIleitis&Colitis
[09]=AmericanDiabetesAssociation[33]=DeafnessResearchFndn[71]=NationalKidneyFoundation
[11]=AmericanFedforAgingResearch[37]=DermatologyFoundation[75]=NatlMultipleScierosisSociety
[13]=AmericanHeartAssociation[39]=DisabledAmericanVeterans[79]=ParalyzedVeteransofAmerica
[15]=AmericanKidneyFund[43]=EpilepsyFoundation[83]=RobertWoodJohnsonFndn
[17]=AmericanLegion[47]=JuvenileDiabetesFndn[87]=SmokelessTobaccoResCouncil
[19]=AmericanLungAssociation[51]=LupusFoundation[91]=SpinalCordSociety
[21]=AmericanNarcoiepsyAssoc[55]=MarchofDimes[95]=VAPrivateResearchCorp
[23]=ArthritisFoundation[59]=MuscularDystrophyAssociation[99]=Other(SpecifyName)
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