Fillable OR-5 Form E-Version Allowing Digital Image Signature For PIs - OR-5_Form_June-2011-2

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OR-5 Form E-Version Allowing Digital Image Signature For PIs - OR-5_Form_June-2011-2

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Country of origin: CANADA
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OR-5 Form
(revised June 2011)
RESEARCH PROPOSAL APPROVAL FORM
Office of Research Use Only
COMPLETE:
Date received COMPLETE:
For data entry:
OR-5 Form [ ]
Account no.
Proposal [ ]
Date returned to PI:
Project no.
Budget [ ]
Sponsor code
Page 1 of 3
Basic Proposal Information
External Deadline Posted by Sponsor (dd/mm/yyyy):
Principal Investigator (or Co-Investigator, if project led by PI at another institution):
Department/School/Centre:
Title of Proposed Project (max 50 chars):
Sponsor (e.g., NSERC): Program (e.g., Discovery Grant):
Budget Information
Exemptions (if any e.g. ARIO RSSA fees)
Please specify Indirect Costs if not
25% (grants) or 40% (contracts):
Maximum allowable – attach copy of
published guidelines from sponsor
Other negotiated rate – attach approval
from AVPR/VPR
All other Direct Costs of research (eligible to
calculate Indirect Costs)
SUBTOTAL (Exemptions + other Direct Costs)
Indirect Cost Rate (either 25% or 40%)
Indirect Costs (other Direct Costs x Rate)
TOTAL (SUBTOTAL + Indirect Costs)
Detailed Proposal Information
1. PROJECT FUNDING SOURCES Yes No
(a) Are there previously signed agreements which may impact this proposal
(for example, terms on intellectual property)? If so please specify account or
agreement:
(b) Does this proposal depend on matching or leveraged funds from other sources?
If so please provide a list of these projects (or attach separate pages):
Award period
(e.g., 01/01/2011 to
30/12/2011)
Amount of funding
($ CDN)
Trust account number
OR OMAFRA
Project #
(dd-mmm-yyyy)
0.00
Indirect Cost Rate (either 0.25 or 0.40)
0.00%
0.00
0.00
Page 2 of 3
2. RESOURCE USE Yes No
(a) Will the proposed research make use of any OMAFRA Research Stations or
Campus Animal Facilities?
If Yes, please complete and attach relevant budget templates.
(b) Is faculty release time or faculty pay requested?
If Yes, please specify:
(c) Is new construction, equipment installation, or renovation required?
If Yes, please attach cost estimate from Physical Resources.
(d) Is additional space required?
3. INTERNATIONAL RESEARCH
(a) Does this proposal involve a topic relating to another country?
OR
(b) Does this proposal involve collaborations with an institution/organization
outside of Canada?
If Yes to either (a) or (b) above, or both, please specify:
a) Country(ies):
b) Project purposes:
Research
Development
Teaching
Training
Evaluation
Conference(s)
Other (please specify)
a) Collaborating institution(s)/organization(s) and their associated countries:
Collaborating institution(s)/organization(s)
Country
Certifications
Yes
No
Will
involve
at later
date
Approval
Obtained
Protocol #
For new protocol or protocol updates, go to the relevant
website link.
Live Animals
Animal Care Services ext. 56632
Biohazardous Materials
Environmental Health & Safety Office ext. 53190
Controlled Drugs
OVC Pharmacy for Health Canada Exemption ext. 54196
Drugs
Drug Use Form ext. 54196
Hazardous Substances
Environmental Health & Safety Office ext. 56401
Human Participants
Research Ethics Services ext. 58024
Radioactive Materials
Environmental Health & Safety Office ext. 54888
Radiation Emitting Devices
Environmental Health & Safety Office ext. 54888
Transgenic Animals/Plants
Research Risk Management ext. 52048
OVC Health Sciences
Centre Resources
OVC Health Sciences Centre ext. 54102
Page 3 of 3
Declaration of Financial Interest
Yes No
Do you have any financial interest in the sponsor or industry partner(s)
associated with this project?
Members of the University Community have a responsibility to ensure that conflicts of interest, including financial relationships,
wherever and whenever they arise, are identified and disclosed to the next person in the line of authority within the University so that
the conflict situation will be addressed and, if possible, accommodated.
Department/School and College authorization below of this proposal/application verifies that such disclosure has taken place and that
the conflict has been addressed.
For further information or assistance please contact the Associate Vice-President (Research Services).
Policies and guidelines that address conflicts of interest can be found in the UGFA Collective Agreement (Article 8), Guidelines on
the Acceptance of Research Support, and the Policy on Responsibilities of Advisors, Advisory Committees and Graduate Students
and Graduate Student-Advisor Mediation Procedures.
Signatures from PI, Department/School and College
Principal Investigator
Department Chair/
School Director (or
designate)
Dean of College (or
designate)
University
Signing Authority
Signature
Signature
Signature
Signature
Print name & title
Print name & title
Print name & title
Print name & title
Date
Date
Date
Date
Shayan Sharif
Associate Dean, Research
and Graduate Studies
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Completed 16 March 2020

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