UW-Stout--Student Research Fund Grant

Application Cover Sheet

Check one:

_____This is a Research Grant Proposal      _____This is a Dissemination Grant Proposal

Provide contact information for all students involved: (attach additional sheet if necessary)

Name: _________________________________ Email Address: ________________________

Check One: ___ Freshman   ___ Sophomore   ___ Junior   ___ Senior   ___ Graduate*

* Do you have a graduate assistantship?  ___ Yes  ___ No 

Signature: ______________________________ Phone Number: ________________________

===============================================================

Name: _________________________________ Email Address: ________________________

Check One: ___ Freshman   ___ Sophomore   ___ Junior   ___ Senior   ___ Graduate*

* Do you have a graduate assistantship?  ___ Yes  ___ No 

Signature: ______________________________ Phone Number: ________________________

===============================================================

Name: _________________________________ Email Address: ________________________

Check One: ___ Freshman   ___ Sophomore   ___ Junior   ___ Senior   ___ Graduate*

* Do you have a graduate assistantship?  ___ Yes  ___ No 

Signature: ______________________________ Phone Number: ________________________

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Project Title: _____________________________________________________________

Project Beginning Date: _________________Project Ending Date: ______________

Budget Requested from Student Research Fund: _________________

Research Involving Human Subjects: A human subject is defined as a living individual about whom an investigator obtains either (1) data through intervention or interaction with the individual; or (2) identifiable private information. If your research involves Human Subjects, please see the Human Subjects web site: http://www.uwstout.edu/rs/humansubjects.shtml

Have you completed Human Subjects Training? (if applicable) ___Yes ___ No

If you answered "Yes" to this question, please attach the Certification of Completion of Human Subjects Training to this form

By signing this form the research advisor agrees to:

• Provide supervision on the research and budget for the proposed project
• Review this application prior to signing for content and professional presentation
• Assist student with transportation & lodging arrangements and reimbursement (to assure compliance with University rules/regulations)
• Assist student with purchases and reimbursement (to assure compliance with University rules/regulations)

I have reviewed the final proposal and approve this project:

Research Advisor's Name:___________________________________

Department:______________________________________________

Signature:______________________________Date______________