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 PROJECT 6. 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 SUBJECTS YES NO
YES
NO
RADIOISOTOPES
YES
INVESTIGATIONAL
INVESTIGATIONAL DEVICES
NO
BIOHAZARDS YE
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
FEMALES YES NOAGENT 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
VA FORM
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.
VA FORM
JUN 1989
Page 2
10-1436
INSTRUCTIONS FOR COMPLETING VA FORM 10-1436 - PROJECT DATA SHEET
GENERAL:
A Project Data Sheet (VA Form 10-1436) is required (M-3, Part I, Change 4) for research involving VA
facilities, resources, employees, or patients. An initial Project Data Sheet must be submitted within 15 days
after the initiation of the project. A Progress report must be submitted annually thereafter.
If the principal investigator (or co-principal investigator) has not completed an Investigator Data Sheet (Page
18 -VA Form 10-5368) at this medical center, a completed Investigator Data Sheet must be returned with this
Project Data Sheet.
Projects funded by Cooperative Studies are reported only by the Study Chairperson. HSR&D Field Programs
are reported only by the HSR&D Field Program Director. For projects with co-principal investigator(s), submit
only one Project Data Sheet, arbitrarily designating one co-principal investigator as principal investigator
responsible for completing the Project Data Sheet. Report the remaining co-principal investigator(s) in item 10.
SPECIFIC ITEMS:
Principal/Co-Principal Investigator--All Principal Investigators (and Co-Principal Investigators)
must have a VA appointment. If the Principal Investigator of the project does not have a VA
appointment, but if a portion of the project is to be done at the VA by a VA investigator, enter
the VA investigator as the Principal Investigator and code item 5 (below) as "02".Only one
name is to be entered in this space.
Item 3:
Item 5:
Status of PI in Project--Mark "02" only if you are not the recipient of the grant or award or not
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.
Project Title Change--If the project title has changed since last report, mark "YES." A title
change is permissible ONLY if there is NOT a change in funding source(s) (see item 12).
Item 9:
Item 10: In the case of Co-Principal Investigators, list one as Principal Investigator in item 1. Do not
enter the names of Co-Investigators or anyone who does not have a VA appointment.
Item 11:
Funding and Administration--Funding and Administrative codes are on the back of this page. It
is possible to designate up to three funding sources and administrative codes for a single
project. Do NOT, however, use a generic title for your research projects and designate multiple
funding sources for your overall effort. Keep projects separate.
Item 14: Key words are checked against the Medical Subject Heading (MeSH) index which is maintained
by the National Library of Medicine. A list of these terms is located in the Research Office or
the VA library.
Item 15:
Project Abstract--Organize abstract 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.
VA FORM
JUN 1989
10-1436
Page 3
FUNDING SOURCE CODES
[03] = Dept of Defense [15] = Food and Drug Admin [27] = Natl Science Foundation
[05] = Dept of Education [17] = Health Resources & Svcs Admin [29] = Rehabilitation Svcs Admin
[07] = Dept of Energy [19] = Natl Inst of Occupational Safety [35] = U.S. Public Health Service
[09] = Dept of Health & Human Services [21] = Natl Aeronautics & Space Admin [99] = Other (Specify Name)
[11] = Dept of Labor [23] = Natl Center for Health Svcs Rsch
[13] = Environmental Protection Agency [25] = Natl Library of Medicine
[03] = Natl Cancer Institute [23] = Natl Inst of Nursing
[05] = Natl Eye Institute [25] = Natl Inst on Aging
[07] = Natl Heart, Lung, & Blood Institute [27] = Natl Inst on Alcohol Abuse and Alcoholism
[09] = Natl Inst of Allergy and Infectious Disease [29] = Natl Inst on Arthritis
[11] = Natl Inst of Child Health & Human Development [31] = Natl Inst on Deafness & Other Common Disorders
[13] = Natl Inst of Dental Research [33] = Natl Inst on Drug Abuse
[15] = Natl Inst of Diabetes, Digestive & Kidney Disease [35] = Natl Inst on Mental Health
[17] = Natl Inst of Environmental Health Sciences [37] = Division of Research Resources
[19] = Natl Inst of General Medical Sciences [43] = NIH - Institute not known at present
[21] = Natl Inst of Neurological & Communicative Disorders
[01] = Affiliated University [05] = Local Government [09] = Foreign Government
[03] = Private Donor [06] = State Government [99] = Other (Specify Name)
[01] = A.H. Robbins [29] = E.R. Squibb [54] = Marion [79] = Rorer
[03] = Abbott [31] = Eli Lilly [56] = McNeil [81] = Ross
[05] = Adria [33] = G.D. Searle [58] = Mead Johnson [83] = Sandoz
[07] = Alpha Therapeutic [34] = G.H. Besselaar [60] = Merck Sharpe & Dohme [84] = Schering
[08] = American Cyanamid [36] = Genetech [62] = Merrell-Dow [85] = Smith Kline
[09] = Ayerst [38] = Glaxo [64] = Miles [87] = Sterling-Winthrop
[11] = Beecham [40] = Hoechst-Roussei [66] = Norwich Eaton [89] = Stuart
[13] = Boehringer Ingelheim [42] = Hoffman-La Rouche [68] = Organon [91] = Syntex
[15] = Boots [44] = Hybritech [70] = Ortho [93] = Upjohn
[17] = Bristol-Meyers [46] = Janssen [73] = Parke-Davis [95] = Warner-Lambert
[19] = Burroughs Wellcome [48] = Knoll [75] = Pfizer [97] = Wyeth
[21] = Ciba-Geigy [50] = Lederle [76] = Purdue Frederick [99] = Other (Specify Name)
[25] = Dupont [52] = Lorex [78] = Roche
2. National Institutes of Health (Enter "91" followed by Item Code: eg, National Eye Institute = 9105)
[02] = Research Advisory Group (Prog 821; CC 103) [09] = Other Designated Research (Prog 821; CC 109
[03] = Merit Review (Prog 821; CC 103) [22] = Rehabilitation R&D (Prog 822)
[06] = Special Research Initiatives (Prog 821; CC 106) [23] = Agent Orange and Related Herbicides (Prog 823)
[07] = Cooperative Studies (Prog 821; CC 107) [24] = Health Services R&D (Prog 824)
[08] = Career Development (Prog 821; CC 108)
[01] = No Funding (Funding Code is "0000") [05] = DVA - General Post Funds
[02] = DVA funds (Funding Code begins with "90") [06] = DVA - Private Research Corporation
[03] = DVA - Reimbursed from another Federal Agency [07] = Affiliated University
[04] = DVA - Direct grant [08] = Other Agency
3. Other Federal Government Agency (Enter "92" followed by Item Code: eg, Department of Energy = 9207)
4. Academic Institution, Private Donor, or Other Government (Enter "93" followed by Item Code)
5. Private Proprietary Company (Enter "97" followed by Item Code: eg, Eli Lilly = 9731)
6. Voluntary Agency or Foundation (Enter "98" followed by Item Code: eg, March of Dimes = 9855)
7. None (Enter 0000)
ADMINISTRATIVE CODES
VA FORM
JUN 1989
1. Department of Veterans Affairs (Enter "90" followed by Item Code: eg, Career Development = 9008)
[03] = Alzheimer’s Dis & Related Dis Assoc [27] = Council for Tobacco Research [63] = National Dairy Council
[05] = American Cancer Society [31] = Cystic Fibrosis Foundation [67] = Natl Fndn Ileitis & Colitis
[09] = American Diabetes Association [33] = Deafness Research Fndn [71] = National Kidney Foundation
[11] = American Fed for Aging Research [37] = Dermatology Foundation [75] = Natl Multiple Scierosis Society
[13] = American Heart Association [39] = Disabled American Veterans [79] = Paralyzed Veterans of America
[15] = American Kidney Fund [43] = Epilepsy Foundation [83] = Robert Wood Johnson Fndn
[17] = American Legion [47] = Juvenile Diabetes Fndn [87] = Smokeless Tobacco Res Council
[19] = American Lung Association [51] = Lupus Foundation [91] = Spinal Cord Society
[21] = American Narcoiepsy Assoc [55] = March of Dimes [95] = VA Private Research Corp
[23] = Arthritis Foundation [59] = Muscular Dystrophy Association [99] = Other (Specify Name)
10-1436
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