Use only if preparing an application witfi IVIultiple PDs/Pls. See http://qrants.nih.qov/qrants/multi pi/index.htm for details. ContactProgramDirector/PrincipalInvestigator(Last,First,Middle):Zwickey,HeatherL. 3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR 3a. NAME (Last, first, middle) Zwickey, Heather L. 3c. POSITION TITLE Dean of Research, Director - Helfgott Research Institute 3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT School of Research and Graduate Studies 3f. MAJOR SUBDIVISION 3g. TELEPHONE AND FAX (Area code, number and extension) TEL: 503-552-1742 FAX: 503-227-3750 3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR 3a. NAME (Last, first, middle) Booth-La Force, Cathryn 3c. POSITION TITLE Professor 3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT University of Washington School of Nursing 3f. MAJOR SUBDIVISION Family and Child Nursing 3g. TELEPHONE AND FAX (Area code, number and extension) TEL: (206) 543-8074 FAX: (206) 685-3349 3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR 3a. NAME (Last, first, middle) 3c. POSITION TITLE 3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT 3f. MAJOR SUBDIVISION 3g. TELEPHONE AND FAX CArea code, number and extension) TEL: FAX: 3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR 3a. NAME (Last, first, middle) 3c. POSITION TITLE 3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT 3f. MAJOR SUBDIVISION 3g. TELEPHONE AND FAX (Area code, number and extension) TEL: FAX: PHS 398 (Rev. 08/12 Approved Ttirough 8/31/2015) 3d. MAILING ADDRESS E-MAIL ADDRESS: 3b. DEGREE(S) 3d. MAILING ADDRESS E-MAIL ADDRESS: Face Page-confinued 3b. DEGREE(S) 3h. NIH Commons User Name PhD hzwickeypi 3d. MAILING ADDRESS (Sfreef, city state, zip code) 049 SW Porter Street Portland, Oregon 97201 E-MAIL ADDRESS: hzwickey(gncnm.edu 3b. DEGREE(S) 3ti. NIH Commons User Name PhD Booth-LaForce 3d. MAILING ADDRESS (Street, city state, zip code) Box 357262 Seattle, WA 98195-9472 E-MAIL ADDRESS: lbcb@u.washington.edu 3b. DEGREE(S) 3h. NIH Commons User Name (Sfreef, city, state, zip code) 3ti. NIH Commons User Name (Sfreef, city state, zip code) OMB No. 0925-0001 Form Page 1-contlnued Program Director/Principal Investigator (Last, First, Middle): Z w l c k c y , H e a t h e r L. FROM THROUGH DETAILED BUDGET FOR INITIAL BUDGET PERIOD DIRECT COSTS ONLY 01/01/2015 12/31/2015 List PERSONNEL (Applicant organization only) Use Cal, Acad, or Summer to Enter Months Devoted to Project Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits ROLE ON Cal. Acad. Summer INST.BASE SALARY FRINGE NAME PROJECT Mnths Mnths Mnths SALARY REQUESTED BENEFITS TOTAL Heather Zwickey PD/PI 2.4 136,999 27,400 6,302 33,702 Ryan Bradley Assistant Pr 6 105,000 52,500 8,400 60,900 Heather Schiffke 3 48,572 12,143 2,793 14,936 Clinical Faculty TBN Faculty 3.6 80,000 24,000 5,520 29,520 SUBTOTALS 116,043 23,015 139,058 CONSULTANT COSTS EQUIPMENT (Itemize) SUPPLIES (Itemize by category) TRAVEL Trainee, administrator and faculty travel to in-person meetings with partner organization 5,100 INPATIENT CARE COSTS OUTPATIENT CARE COSTS ALTERATIONS AND RENOVATIONS (Itemize by category) OTHER EXPENSES (Itemize by category) Curriculum enhancement, software 24,960 CONSORTIUM/CONTRACTUAL COSTS DIRECT COSTS SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page) 169,118 CONSORTIUM/CONTRACTUAL COSTS FACILITIES AND ADMINISTRATIVE COSTS TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD 169,118 PHS 398 (Rev. 08/12 Approved Through 8/31/2015) OMB No. 0925-0001 Page 4 Form Page 4
