MERIT REVIEW APPLICATION
1. LAB NO. 2. APPLICATION NO. 3. REVlEW GROUP 4. REVIEW DATE 5. FACILITY NO.
6. LOCATION HEALTH CARE FACILITY (VAMC, OPC, CITY, STATE)
7. SOCIAL SECURITY NO.
8. DATE OF LAST SUBMISSION -MR
9. PRINCIPAL INVESTIGATOR(S) (Last Name, First Name, M.i. )
DEGREE
TELEPHONE NUMBERS(S)
10. PROGRAM TITLE (72 Characters maximum)
11. AMOUNT REQUESTED EACH YEAR
1ST 12. VA EMPLOYMENT STATUS FULL TIME PART TIME (
2ND
3RD 13. VA SALARY SOURCE RESEARCH CC 103
4TH PATIENT CARE HSR&D RR&D OTHER VA
5TH
TOTAL
/8 TIME)
RESEARCH CC 104 RESEARCH CC 105 RESEARCH CC 110 CAREER DEVELOPMENT CC 108
CONSULTIN ____ HRS./WEEK ATTENDING ____HRS./WEEK WOC ____HRS. WEEK 15. PROGRAM
COST CENTER
16. PRIMARY RESEARCH PROGRAM AREA
PRIMARY RESEARCH SPECIALTY AREA
17. VA HOSPITAL SERVICE AND SECTION
18. ACADEMIC RANK, DEPARTMENT AND AFFILIATION
19. PROGRAM USE (Each Item must have a response) HUMAN SUBJECTS ANIMAL SUBJECTS YES YES NO NO INVESTIGATIONAL DRUGS INVESTIGATIONAL DEVICES YES YES NO NO RADIOISOTOPE BIOHAZARDS YES YES NO NO
20. SUMMARY OF RESEARCH/ DEVELOPMENT SUPPORT FOR THREE PRIOR TOTAL VA FY TOTAL NON-VA GRAND TOTAL
F
FY 21.DATE ENTERED ON DUTY VA, OR EXPECTED DATE OF ENTRY VA
SIGNATURE PRINCIPAL INVESTIGATOR(S)
Date
SIGNATURE ACOS FOR RESEARCH AND DEVELOPMENT
Date
VA FORM 10-1313-1 DEC 2006
Page 1 of VA Form 10-1313 package