Cayuse Proposal Submission Questions Step 1 of 5 20% This form has been developed for researchers in the College of Information & Communication who are working on proposals with the CCI Research & Innovation Center.The following information is required for Cayuse proposal submissions. Please complete as soon as possible.Name(Required) First Last Email(Required) Conflict of Interest Please refer to the University’s conflict of interest policy and be sure that the research team members have completed an Outside Interest Disclosure form and financial conflict of interest training, if required. Your Campus conflict of interest contact is listed here. Outside Interest Disclosure Form – From this link, select Employee Self-Service tab, and then the Personal Information section choose Outside Interest Disclosure to access your form1. Currently or during the term of this project, does any investigator and/or his or her family members have or expect to have: Note: Family members are defined as an individual’s spouse (whether or not they commingle assets), parents, and children (both dependent and nondependent and including stepchildren and foster children).a) A personal financial interest in this project or personal financial relationship (including compensation or gifts of cash or in-kind) with any entity involved in the study, including sponsor, vendors, subrecipients, or other interested parties (including investigator's family member participating in the project)?(Required) Yes No b) A personal financial interest in or personal financial relationship (including gifts of cash or in-kind) with an entity that owns or has the right to commercialize a product, process, or technology studied in this project?(Required) Yes No c) A board membership of any kind or an executive position (paid or unpaid) with the sponsor of this project or with an entity that owns or has the right to commercialize a product, process, or technology studied in this project or that is otherwise involved with the project?(Required) Yes No 2. Is the proposal being submitted to any agency that falls under the auspices of the Public Health Service (e.g. AHRQ, ATSDR, CDC, FDA, HRSA, IHS, NIH, OIG, SAMHSA, etc.) or that has adopted the PHS policies?(Required) Yes No Regulatory Compliance 1 If this proposal includes the use of hazardous research materials, please check the appropriate category under Research Materials and contact the Environmental Health & Safety Office for any required approvals.1. Does this research involve HUMAN SUBJECTS or have a Not Human Subjects Research (NHSR) determination? (including exempt studies, data collection through surveys, questionnaires, or use of purchased or archived information about individuals)(Required) Yes No 2. Has your research team submitted an application for IRB approval?(Required) Yes No 2a. Please indicate your reason for not submitting an IRB application:(Required) Not required at proposal submission (JIT) Submission is pending 3. Does this research involve ANIMAL SUBJECTS?(Required) Yes No 4. Does the proposal involve research with any of the following? (please check all that apply) Radioactive material or X-ray Producing Machines (including XRF/XRD); Class III B or IV laser systems? Other hazardous substances (poisons, explosives, reagents, flammables, carcinogens, etc.)? Activities that involve significant physical hazards (e.g. Noise > 85 dBA, high pressure, altitude, electrical, or sub-radio frequencies)? Nanomaterials? Materials provided by the sponsor or any other party? Regulatory Compliance 2 NSF’s plan for Safe and Inclusive Working Environments For proposals submitted to NSF (as lead, collaborative, or subcontractor), that include activities off-campus or off-site, a Plan for Safe and Inclusive Working Environments is required for that proposal. A plan is required when any project activities are conducted off-campus/off-site, which includes, but are not limited to research (e.g., gathering samples, user facilities at national laboratories) and disseminating or exchanging project information (e.g., collaboration meetings, conference travel). If UT submits a proposal that includes external parties (e.g., sub-awardees, consultants, volunteers) conducting project activities in a location other than their location of normal operations, a plan is required. https://research.utk.edu/research-integrity/safety/1. Is this proposal being submitted to NSF and includes activities that require a Plan for Safe and Inclusive Working Environments as described above?(Required) Yes No 1a. Confirmation (check box)(Required) I confirm a Plan for Safe and Inclusive Working Environments has been developed for this proposal and will be disseminated to personnel before traveling. Biohazard Material Identification Select “No biohazard materials are used in this research” if appropriate. Otherwise, select the primary biohazard. If using biohazard materials, contact campus Biosafety.Biohazard Primary(Required)No biohazard materials are used in this researchRecombinant DNA/transgenic animals or plantsAgents infectious to humans, animals, or plantsHuman or nonhuman primate materials (e.g., blood, tissue, body fluids, cell lines)Biological toxins (LD<100Kg/ in vertebrates)Select Agents and/or Select Toxins Select any additional biohazards other than the primary using the checkboxes below.(Required) No biohazard materials are used in this research Recombinant DNA/transgenic animals or plants Agents infectious to humans, animals or plants Human or nonhuman primate materials (e.g. blood, tissue, body fluids, cell lines) Biological toxins (LD50<100ng/kg/ in vertebrates) Select Agents and/or Select Toxins (Select Agents and/or Select Toxins: https://www.selectagents.gov/sat/list.htm?CDC_AA_refVal=https%3A%2F%2Fwww.selectagents.gov%2FSelectAgentsandToxinsList.html) Export Control It is the responsibility of the PI to identify any items, technology, or activities on a proposal that may have export-control implications. For any questions related to export control, please contact your campus export control office. Some types of research may have export control implications even if all work is conducted within the U.S.1. Does the proposed work involve any of the following, or do you have any other reason to believe it may involve export control or security concerns? Homeland Security concerns Restricted Department of Energy technology Spacecraft technology (U.S. Government) or DoD Form 2345 Militarily Critical Technical Data Agreement1a(Required) Yes No 2. Do you anticipate that the project work may involve: a. (1) Traveling outside the US or (2) Sending, transporting, transmitting, or carrying any material or equipment related to this project outside the US (examples include: GPS, biologicals, diagnostic kits, reagents)?(Required) Yes No A foreign national/person is any person who is NOT: a U.S. citizen; granted permanent residence as demonstrated by the issuance of a permanent resident visa (i.e. “Green Card”); or a “protected person” as defined by 8 USC 1234b(a)(3). It also means: any foreign corporation; business association; partnership; trust; society; or any other entity or group that is not incorporated or organized to do business in the United States, as well as international organizations, foreign governments and any agency or subdivision of foreign governments (eg. diplomatic missions). Examples include: graduate assistant from other country, visiting scholar, international collaborator on research team, etc.b. Does this project involve work with foreign nationals, as defined above?(Required) Yes No c. Transmitting funds (through payments, for example) or goods or technology to any of the following countries on the Sanctions Programs and Country Information.(Required) Yes No (Sanctions Programs and Country Information: https://ofac.treasury.gov/sanctions-programs-and-country-information)3. Do you anticipate that the project work may involve:a. Non-commercial encryption or information security software or any classified materials, equipment, technology, or data?(Required) Yes No b. Any equipment, technology, materials, software, or other defense articles listed on the United States Munitions List (USML) under the International Traffic in Arms Regulations (ITAR), or specifically designed, modified, or adapted (even slightly) for a military purpose, or that may involve national security?(Required) Yes No (International Traffic in Arms Regulations (ITAR): https://www.pmddtc.state.gov/ddtc_public?id=ddtc_kb_article_page&sys_id=%2024d528fddbfc930044f9ff621f961987)c. Does the research involve technology or equipment with a strong potential dual-use (civilian and military) application listed on the Commerce Control List (CCL) under the Export Control Regulations (EAR)?(Required) Yes No (Export Control Regulations (EAR): http://www.bis.doc.gov/index.php/regulations/export-administration-regulations-ear) Intellectual Property For Confidentiality Agreements/Nondisclosure Agreements (CDAs/NDAs) only, please mark “no” to any questions if you do not know the answer or do not yet know what product/technology may be involved.1. Have you disclosed any of this research to the UT Research Foundation as an invention/discovery/copyrightable material?(Required) Yes No UT Research Foundation2. If you have made a disclosure for any of this research to the UT Research Foundation, are there any agreements or intellectual property in place?(Required) Yes No 3. Would you like UTRF to contact you regarding the commercial potential of this research?(Required) Yes No 4. Will this research require any information, data, or materials from a third party under a confidentiality agreement, non-disclosure agreement, material transfer agreement, etc.(Required) Yes No If yes, please be prepared to provide identifying information, data, or material provider(s), if available.5. Is this proposal related to an SBIR (Small Business Innovative Research) or STTR (Small Business Technology Transfer Research) Program?(Required) Yes No If yes, please identify the prime applicant and other non-UT participants. 6. Do you anticipate having any unpaid students (undergraduate or graduate) working on this project who will influence the design, conduct, or reporting of the project or activities?(Required) Yes No 7. Do you anticipate having any unpaid students (undergraduate or graduate) involved in this project participating only to acquire training in research methodologies and skills?(Required) Yes No Δ