Fillable Mini-Grant Application 2 URECA! MINI-GRANT FORM -TTU

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Mini-Grant Application 2 URECA! MINI-GRANT FORM -TTU

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URECA! MINI-GRANT FORM -TTU
APPLICATION FOR URECA! MINI-GRANT
1. COVER SHEET
Project Title:
Project Begin Date: Project End Date:
(MM/DD/YYYY) (MM/DD/YYYY)
STUDENT INFORMATION (as of today’s date):
Student ID
T#
Name: (required!):
Address: Telephone Number:
Street
Email
Address:
City, State, Zip Code
Major: Minor:
Mentor: Co-Investigator(s):
Freshman 1
st
year Click Checkboxes
Classification: Sophomore 2
nd
year
Junior 3
rd
year Is this a Disciplinary Specific Grant (D) or
Senior 4
th
year is this an Interdisciplinary Grant (I)
Expected Graduation Date:
(Enter Month and Year e.g., May 2015)
Cumulative GPA: Major GPA:
BUDGET: (food is not allowed)
SUPPLIES
OTHER
TOTAL
(requested from grant)
SIGNATURES:
________________________________________
(STUDENT) (DATE)
________________________________________
(FACULTY SPONSOR) (DATE)
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URECA! MINI-GRANT FORM -TTU
2. URECA! BUDGET FORM
(To be developed in consultation with faculty mentor)
Student Name:
Project Title:
DETAILED BUDGET:
Itemize expenses for items not provided through TTU or your faculty mentor. The maximum is $1000 for
academic year mini-grants. Submit separate sheet with supporting documentation (e.g., product specifications,
cost estimates, travel request forms) if appropriate. The budget page should include a list of the items within
categories (i.e., supplies, personal protective equipment, services, equipment, mileage, etc.) and a justification
of any unusual items. Round to the nearest dollar. If the total project costs exceed the $1000 maximum of this
award for academic year mini-grants or $4000 for summer grants, then list any other sources of support (SMAC
606, other grants) on a separate additional sheet.
Expense Items
Estimated Costs
$
$
$
$
$
$
$
Total Budget Request:
$
All funds for expense items, such as materials, supplies, equipment, software, computers, resources, or for other
expenditures such as travel integral to the conduct of the project or costs for outside services performed, must
be clearly and fully documented in the project description in Section 3. Remember, not all committee members
are familiar with your area of study, and as such, they may not fully understand the need for materials, supplies,
travel, and other expenses. Such documentation must include:
• Name/description of expense item
• Cost of expense item
• Detailed justification for why this expense item is necessary
• Brief description of how this item is to be used for this project
• Can the project be completed without the requested item(s)?
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0
URECA! MINI-GRANT FORM -TTU
3. PROJECT DESCRIPTION: The student must complete this section in her/his own words.
Have your advisor review it to ensure that you both agree on its contents.
The Project Description consists of the following sections:
• Introduction/Background (include your main research question and/or creative outcome; use
supporting citations)
• Describe what you plan to do during the course of the project
• Explain how the project extends both your own present knowledge and contributes to your
field of study; explain its value and to whom.
• Define the role of your faculty advisor: describe how you will collaborate, how often you
will meet, what, if any, direct responsibilities your advisor will have to the positive outcome
of the project.
NOTE: This description must be written to an educated lay audience.
The review committee will not necessarily contain a member from your field.
[INSERT PROJECT DESCRIPTION here or add additional pages:
~THREE PAGES or 1500 WORD MAXIMUM]
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URECA! MINI-GRANT FORM -TTU
4. Environmental Health and Safety (check all that apply to your proposed research)
Infectious Agents (including Select Agents)
Human Derived Materials
Recombinant DNA
Hazardous Chemicals (including controlled substances)
Will hazardous wastes be generated?
Yes
No
Plant Pathogens (including Select Agents)
Compressed gases
Cryogenic materials
Noise
Nanoparticles
Non-native/Invasive species
Shipping/receiving and/or transporting hazardous materials (including dry ice, chemicals, and biological
materials)
Radionucleotides
Ionizing radiation/Lasers
Aquatic hazards (diving/boat/etc.)
If any box above is checked your application must also be reviewed by Environmental Health and Safety. For
guidance in defining research hazards, please consult the EHS website: www.tntech.edu/safety
Vertebrate Animals
http://www.tntech.edu/research/animal-care-and-use-iacuc/
1. Does the research proposed in this application involve the use of vertebrate animals?
No. (Review by IACUC is NOT required. Do not answer Question 2.)
Yes. (Review by IACUC is required. Continue with Question 2.)
2. A protocol for the research proposed in this application (check one):
has been approved and is on file in the IACUC.
has been submitted to the IACUC.
will be submitted to the IACUC.
Page 4
URECA! MINI-GRANT FORM -TTU
Human Subjects
http://www.tntech.edu/research/hs-guidelines/
1. Does the research proposed in this application involve the use of human subjects (INCLUDING use of
de-identified data or specimens of human origin)?
No. (Review by the TTU Institutional Review Board is NOT required. Do not answer Question 2
in Safety Training.)
Yes. (Review by TTU Institutional Review Board is required. Continue with Question 2 in Safety
Training.)
Include in the URECA! application your IACUC and/or IRB application(s) and/or approval letter(s).
Note: No funding will be given prior to the receipt of the necessary approval, but applications will still be
accepted.
Safety Training
1. Have you completed all appropriate required TTU safety training?
Yes (Answer question 2)
No
2. Which TTU safety training(s) have you completed? List training title and date of completion. Note: TTU
safety training(s) are required prior to the start of any project.
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URECA! MINI-GRANT FORM -TTU
5. HEALTH and SAFETY
Consider your project from start to finish. What health and safety related issues are involved with the work you
will perform? What precautions will be taken to minimize the risks? Be sure to include information about
wastes generated, hazards present in the research project, environmental protection, and precautions to be taken
to protect yourself and others around you. (250 word maximum)
[INSERT HEALTH/SAFETY/ETHICS STATEMENT: 250 WORD MAXIMUM]
6. Ethics
Are there ethical considerations related to your project? (250 word maximum)
Ethics Signature Statement
By signing below, I (the student) certify that all information provided in this application is accurate and not
plagiarized.
Student Signature Date
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URECA! MINI-GRANT FORM -TTU
7. LEARNING OBJECTIVES AND CAREER NARRATIVE:
Describe what you will learn, skills you will develop, and/or techniques that you will use and how
this will enhance your career goals.
[INSERT OBJECTIVES AND CAREER NARRATIVE: 500 WORD MAXIMUM]
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URECA! MINI-GRANT FORM -TTU
8. FACULTY MENTOR’S SUPPORT FORM
To be completed by faculty mentor. Must be signed and included with student application’s packet. Application Information:
Student Name: _______________________________________________________________________
Project Title: _________________________________________________________________________
Faculty Mentor Information:
Name:______________________________________________ Rank:___________________________
College/School:______________________________________ Department:_________________________
Telephone:____________________ Campus Box: __________________
Email Address:________________________________________
Is IRB Approval Required? Yes No If yes, has it been secured? Yes No
Institutional Review Board for the Protection of Human Subjects at Tennessee Technological University
Is Performance License, Royalties, or Copyright Permission Required? Yes No
If yes, has it been secured? Yes No
Is IACUC Approval Required? Yes No If yes, has it been secured? Yes No
Institutional Animal Care and Use Committee
Has the Student taken all required safety courses? Yes No
If you have more than one student applying for the same type of URECA! GRANT, but are NOT on the same project please
rank this student/project in comparison to the other students (1 of 2 , etc.) Rank:
of
Faculty Mentor Endorsement:
Please complete the following Faculty Mentor Endorsement form describing the merit of the
project and its potential impact on the student, the student’s potential for successful completion, and your role in the project. Your
comments are very influential in the committee’s decision. Please Type.
1) Please provide comments on the merit of this project and its potential impact on the student’s engagement in
research, scholarship, and/or creative activity.
2) Please comment on the student’s potential for successfully completing the project.
3) Please comment on your role in this project.
Mentor Signature Date
My department chair is aware of this project and is supportive of the project and my involvement as a faculty mentor.
Page8
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Completed 8 March 2020

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