FormApprovTehdrou0g5h/2004 Department of Health and Human Services Public Health Services Grant Application Do not exceed 56-character length restrictions, including spaces. 1. TITLE OF PROJECT Biology of GDNF in Diabetic Neuropathy OMBNo. 0925-0001 LEAVE BLANKmFOR PHS USE ONLY, Type J Activity Number Review Group Formerly Council/Board (Month, Year) Date Received 2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION [] NO [] YES (If 'Yes,' state number and title) Number: PA-99-159 Title:The Role of Growth Factors 3. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR 3a. NAME (Last, first, middle) Stucky, Cheryl L. 3c. POSITION TITLE Assistant Professor 3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT Cell Biology, Neurobiology & Anatomy 3 MAJOR SUBDIVISION School of Medicine 3g. TELEPHONE AND FAX (Area code, number and extension) TEL: 414-456-8373 FAX: 414-456-6517 No [] Yes 4c. NIH-defined Phase III Clinical Trial [] No [] Yes 7. COSTS REQUESTED BUDGETPERIOD 7a. Direct Costs ($) 50,000 4. HUMAN SUBJECTS 4a. Research Exempt [] RESEARCH If'Yes,' Exemption No. __ [] No 4b. Human Subjects Assurance No. [] Yes 6. DATES OF PROPOSED PERIOD OF SUPPORT (month, day, year--MM/DD/YY) From 12/01/02 J Through11/30/07 9. APPLICANT ORGANIZATION Name Medical College of Wisconsin Address 8701 Watertown Plank Road PO Box 26509 Milwaukee, WI 53226-0509 Institutional Profile File Number (if known) & 6001 12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE Name Rodney W. Kison Title Director, Grants & Contracts Address Medical College of Wisconsin PO Box 26509 Milwaukee, WI 53226-0509 Tel 414-456-8507 FAX 414-456-6555 E-Mail grants@rncw.edu in the Development of Diabetes Complications Newlnvestigator [] No [] Yes 3b. DEGREE(S) PhD 3d. MAILING ADDRESS (Street, city, state, zip code) Medical College of Wisconsin Dept of Cell Biology, Neurobiology & Anatomy 8701 Watertown Plank Road PO Box 26509 Milwaukee, WI 53226-0509 E-MAIL ADDRESS: cstucky@mcw.edu 5. VERTEBRATE ANIMALS [] No [] Yes 5a. If'Yes,' IACUC 11/15/00 approval Date 5b. Animal welfare assurance no A-3102-01 FORINITIAL 8. COSTS REQUESTED FOR PROPOSED PERIOD OF SUPPORT 7b. Total Costs ($) 8a. Direct Costs ($) 8b. Total Costs ($) 75,000 250,000 375,000 10. TYPE OF ORGANIZATION Public: --> [] Federal [] State [] Local Private: --> [] Private Nonprofit For-profit:--> [] General [] Small Business [] Woman-owned [] Socially and Economically Disadvantaged 11. ENTITY IDENTIFICATION NUMBER 1390806261A3 DUNS NO. (if available) 93-763-9060 Congressional District 5 13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION Name William Hendee, Ph. D. Title Sr. Assoc. Dean for Research Address Medical College of Wisconsin 8701 Watertown Plank Road PO Box 26509 Milwaukee, Wl 53226-0509 Tel (414) 456-4402 FAX (414) 456-6554 E-Mail grants@mcw, edu 14. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of this application. 15 APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with Public Health Services terms and conditions if a grant is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. PHS 398 (Rev. 05/01) Face SIGNATURE OF PI/PD NAMED IN 3a. (In ink. _;_/_' _i_Inature not aocep.t_e._ .,_ , SIGNATURE OF'_FFICIAL NA_ (In ink. 'Per' signature not acceptable.) ,.i Page Form Page I ========================================Section End===========================================
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