Free VA Form 10-1313-1 - Merit Review Application - fillable - Federal


File Size: 729.0 kB
Pages: 1
Date: December 19, 2006
File Format: PDF
State: Federal
Category: Veterans Forms
Word Count: 214 Words, 1,376 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.va.gov/vaforms/medical/pdf/vha-10-1313-1FILL.pdf

Download VA Form 10-1313-1 - Merit Review Application - fillable ( 729.0 kB)


Preview VA Form 10-1313-1 - Merit Review Application - fillable
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