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The Pediatric Research Resource Office (PRRO) is looking forward to assisting you! Please complete the survey below. This will allow us to determine the appropriate team member to assign to your project.
	Today's Date: * must provide value	TodayM-D-Y
1	First Name * must provide value
2	Last Name * must provide value
3	Division * must provide value	Ped GastroenterologyPed NephrologyPed Adolescent Medicine and Eating DisordersPed GeneticsPed PulmonologyPed EndocrinologyPed Cardiology-Children's Heart GroupChild Abuse PediatricsPed Critical Care MedicinePed Development MedicinePed RheumatologyPed Hematology/OncologyPed NeurologyPed Infectious DiseaseAcademic General PediatricsPed Allergy and ImmunologyPed Complex Care and Palliative CarePed HospitalistPed NeonatologyPed CT Surgery
4	Email: * must provide value
	Admin contact's email address: * must provide value
5	Working title of project/grant/manuscript/etc:
6	What type of support can we provide? Please select all that apply. * must provide value	Find Funding Opportunities Grant Submission IRB Data Management, Analysis, or Configuration (i.e. REDCap) Request Project Management Support, Coordinator Support, Nurse/Clinical Support, etc. Request Study Start-up Support: CDA, MTA, Bioassurances, Feasibility Determination, etc. Other support Find Funding Opportunities Grant Submission IRB Data Management, Analysis, or Configuration (i.e. REDCap) Request Project Management Support, Coordinator Support, Nurse/Clinical Support, etc. Request Study Start-up Support: CDA, MTA, Bioassurances, Feasibility Determination, etc. Other support
	What type of GRANT submission is this?	New Resubmission Renewal RPPR Other New Resubmission Renewal RPPR Other
	If other, please provide us more information	Expand
	Sponsor/Funder:	NIH Foundation Subaward Internal Other NIH Foundation Subaward Internal Other reset
	Please indicate the NIH funding mechanism and the RFA number: Example: R01, R21, K
	Upload the Funding Opportunity here:	( MB) Upload file
	Name of Foundation:
	Name of Subaward Institution:
	Name of the other sponsor/funder and any other pertinent information:	Expand
	Name of Internal Funding Opportunity:
	Sponsor Deadline: * must provide value	TodayM-D-Y
	Performance site (include building and room number) * must provide value	Expand
	Does your research involve human subjects?	Yes No Yes No reset
	Is this a multi-site study?	Yes No Yes No reset
	Does this research involve interaction or intervention with animal subjects?	Yes No Yes No reset
	Does this research involve the use of any Biohazardous Material as defined in Penn State Policy RP11?	Yes No Unsure Yes No Unsure reset
	Does this research involve the use of radioactive materials, radiation-producing instruments, or lasers?	Yes No Yes No reset
	Does this research involve any of the following: CDC/USDA regulated Select Agents or Toxins, highly toxic reactive or explosive substances, DEA controlled substances, use of physical hazards including pressure vessels (>500psi) or high voltage electricity (>600 volts)?	Yes No Yes No reset
	Have you submitted your study to the IRB?	Yes No Yes No reset
	Do you need help in preparing or editing documents for the IRB?	Yes No Yes No reset
	Do you need help in setting up a study in CATS IRB and submitting your study?	Yes No Yes No reset
	If you are working with a sponsor, have they sent you a Confidential Disclosure Agreement (CDA)?	Yes No Yes No reset
	If you have a copy of the CDA, please upload it here:	( MB) Upload file
	You have indicated that you would like help with ______. Do you have funding for your project? Funding includes internal/departmental support that has already been dedicated to you or this project.	Yes No Pending Yes No Pending reset
	What is the funding source?
	Anticipated funding date:	TodayM-D-Y
	Please elaborate on your project and how you need help.	Expand
	If other support requested, please describe	Expand
	You indicated assistance for ______. If we can help you with another request, please refer back to question #6 or describe here.	Expand
	Follow-up Date & Initials:	Expand
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