PCORI Grant Application - DOC by S0rWomUO


									Program Director/Principal Investigator (Last, First, Middle):

                                                            FORM J: CHECKLIST

 1. TYPE OF APPLICATION. (Check all that apply.)

      NEW application. (This application is being submitted to PCORI for the first time.)

      RESUBMISSION of application. (This replaces an unfunded version.) Enter original application no:

      RENEWAL of grant. (Requests additional funding beyond current year.) Enter current grant no:

      SUPPLEMENT to grant. (Requests additional funding for current year.) Enter current grant no:

      CHANGE of principal investigator. (Enter name of former PI in the following box)

      CHANGE of grantee organization. (Enter name of former organization in the following box)

      FOREIGN application            Domestic grant with foreign involvement (Enter countries involved)

 2. PATIENT-FOCUSED AREAS. (Select all patient-centered questions applicable to proposed
     “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”

       “What are my options, and what are the benefits and harms of those options?”

       “What can I do to improve the outcomes that are most important to me?”

       “How can the health care system improve my chances of achieving the outcomes I prefer?”

 3. TARGET POPULATIONS. (Select all populations that the proposed research will specifically target)

      Underserved or disadvantaged populations

      Specific ethnic or cultural populations

      Disabled populations

      Urban                                Rural                               Both Urban and Rural

       Other (enter information):

       Not applicable

 In signing the application Face Page, the authorized organizational representative agrees to comply with
 the policies, assurances and/or certifications listed in the application instructions and PFA, including all   Check to certify agreement
 references within them, when applicable. If unable to certify compliance, where applicable, provide an
 explanation and place it after this page.

 PCORI Grant Application (Rev. 09/11)                                      Page                                                              Form J

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