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Fellowship Routing Sheet (SU-42FL)
1.Due Date:        Postmark Date  OR    Receipt Date
 2. SPO #
Fellow Name:                                       Phone:                                 Email:        
3. Registered at SU? Yes No
 Residents or Prospective Scholars must  complete appointment verfication form 		4. US Citizen
     or
    Visa?   Type: 		5. Degree:
6.   Faculty Sponsor:  Phone:  Email:
7.   Department Name:  Address: 8. Org Code:  Mail code:
9.   Department
      Contact: 		 Phone:  Email:
10. Person Picking
      Up: 		 Phone:  Email:
11. Check one:              New        Supplement          Transfer         Renewal         Revision    

12. Project location:

  On Campus       Specify Building & Room #   
  Off campus:     Specify Building & Room #
13. Remarks:
14. RESEARCH FOCUS (Check only if highly relevant to the research proposed in this application)
Human Genetics Bioengineering Cancer  AIDS Bioterrorism Satellite EmbryonicStem Cell
15. Agency and Proposal Mailing Address
16. Agency Contact & Title: 17. Project Title:

 

 

    
18. Proposal Budget
Year
Start
End
Stipend
Institutional Allowance
Other
Total
1            
2            
3            
4            
5            
   Total        
  Certification                                   
YES NO   YES NO  
    19. Laboratory Animals     20. Human Subjects
    21. Radiological Hazards     22. Human Blood or Body Fluids
    23. Recombinant DNA molecules     24. Infectious or Biohazardous Agents
    25. Human embryonic or fetal stem cells (if yes, complete Stem Cell Research Tracking Form).
    26. Research involves restrictions on researcher participation or dissemination of results (See Openness in Research policy.)
    27. Has the applicant signed a Patent and Copyright Agreement (SU-18)?
    28. Dept. responsible for 8% infrastructure charge- Provide Dept. PTA #
29. REMINDER: Complete and attach the Disclosure of Financial Interests Related to Research form for this proposal submission
30. Fellow and Faculty Certification
I certify that the information provided about this fellowship agreement is accurate. Furthermore, I certify that I'll conduct my research in compliance with Stanford University policies, the terms of this fellowship agreement, and all applicable laws and regulations.
Faculty Sponsor: Date:
Fellow: Date:
31.Department Approvals
As designee for this department I have reviewed and approved this proposal including the information listed above as required.   I certify that the above information has been reviewed and approved by the department.
Department Administrator Date:
Department Chair*
(*not applicable for School of Medicine Proposals)		 Date:
32. RMG/OSR Office Approvals
Institutional Representative: Date:

SU-42FL 01/06