**VAPHS Financial Schedule for Research Funding Involving Humans**

+-------------+----------------------+------------+---+----------+---+---+---+---+
| **I         |                      |            |   |          |   |   |   |   |
| NVESTIGATOR |                      |            |   |          |   |   |   |   |
| AND PROJECT |                      |            |   |          |   |   |   |   |
| IN          |                      |            |   |          |   |   |   |   |
| FORMATION** |                      |            |   |          |   |   |   |   |
+-------------+----------------------+------------+---+----------+---+---+---+---+
| **Principal |                      |            |   |          |   |   |   |   |
| Inve        |                      |            |   |          |   |   |   |   |
| stigator:** |                      |            |   |          |   |   |   |   |
+-------------+----------------------+------------+---+----------+---+---+---+---+
| **Title of  |                      |            |   |          |   |   |   |   |
| Study:**    |                      |            |   |          |   |   |   |   |
+-------------+----------------------+------------+---+----------+---+---+---+---+
| **MIRB #:** |                      |            |   |          |   |   |   |   |
+-------------+----------------------+------------+---+----------+---+---+---+---+
| **Source of |                      |            |   |          |   |   |   |   |
| Support:**  |                      |            |   |          |   |   |   |   |
+-------------+----------------------+------------+---+----------+---+---+---+---+
| **Duration  |                      |            |   |          |   |   |   |   |
| of          |                      |            |   |          |   |   |   |   |
| Funding:**  |                      |            |   |          |   |   |   |   |
+-------------+----------------------+------------+---+----------+---+---+---+---+
| **Project   |                      | **Project  |   |          |   |   |   |   |
| Start       |                      | Closure    |   |          |   |   |   |   |
| Date:**     |                      | Date:**    |   |          |   |   |   |   |
|             |                      |            |   |          |   |   |   |   |
|             |                      |            |   |          |   |   |   |   |
+-------------+----------------------+------------+---+----------+---+---+---+---+
| **Location  | Veterans Research    |            |   |          |   |   |   |   |
| of Funds:** | Foundation of        |            |   |          |   |   |   |   |
|             | Pittsburgh           |            |   |          |   |   |   |   |
|             |                      |            |   |          |   |   |   |   |
|             | VA General Post Fund |            |   |          |   |   |   |   |
|             |                      |            |   |          |   |   |   |   |
|             | University of        |            |   |          |   |   |   |   |
|             | Pittsburgh           |            |   |          |   |   |   |   |
|             |                      |            |   |          |   |   |   |   |
|             | Other (please        |            |   |          |   |   |   |   |
|             | specify):            |            |   |          |   |   |   |   |
+-------------+----------------------+------------+---+----------+---+---+---+---+

**[Budgetary Breakdown]{.underline}**

Number of Subjects:      

Number of Veteran Subjects:     

Will you be utilizing ancillary services? YES NO

**Ancillary Services Utilized within VAPHS**

Please list the service, unit cost, frequency service performed per
subject, number of subjects to receive the service, and the total cost
for those ancillary services [utilized within the VAPHS
only]{.underline}:

  ---------------- ----------- -------------- --------------- -------------
  **A. Service**   **B. Unit   **C. Frequency **D. Number of  **E. Total
                   Cost**      per Subject**  Subjects**      Cost
                                                              *(BxCxD)***

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     
  ---------------- ----------- -------------- --------------- -------------

**Total Ancillary Costs within VAPHS: \$      **

Will you be utilizing any ancillary services outside of VAPHS? YES NO

**Ancillary Services Utilized outside of VAPHS**

Please list the service, unit cost, frequency service performed per
subject, number of subjects to receive the service, and the total cost
for those ancillary services [utilized outside the VAPHS
only]{.underline}:

  ---------------- ----------- -------------- --------------- -------------
  **A. Service**   **B. Unit   **C. Frequency **D. Number of  **E. Total
                   Cost**      per Subject**  Subjects**      Cost
                                                              *(BxCxD)***

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     

                   \$                                         \$     
  ---------------- ----------- -------------- --------------- -------------

> **Total Ancillary Costs outside of VAPHS: \$     **

**Total Subject Payment *(Payment per subject x \# of subjects)***:
\$     

**Total Cost per Subject *(Add Total Ancillary Costs within VAPHS +
Total Ancillary Costs outside VAPHS+ Total Subject Payment)*:** \$     

**[Budgetary Breakdown (cont'd)]{.underline}**

**[Administrative Fees & Overhead]{.underline}**

  --------------------------------------------------- -------------------
  **Investigational Drug Service Fee:**               \$     

  **IRB Fee:**                                        \$     

  **Research Supplies:**                              \$     

  **Study Start-up Fee (upfront, non-refundable):**   \$     

  **Advertising:**                                    \$     

  **Storage Fee (for storage of research records at   \$     
  study closure):**                                   

  **Institutional Overhead (20%):**                   \$     
  --------------------------------------------------- -------------------

**Total Costs for Administrative Fees & Overhead \$     **

**TOTAL COST OF STUDY *(Add Total Cost per Subject + ***

***Total Costs for Administrative Fees & Overhead):* \$     **

**Annual Salary Breakdown (% and effort)**

  ----------------------- ----------------------- -----------------------
  **Staff Member**        **Annual Salary**       **Percent Effort**

  **     **               **     **               **     **

  **     **               **     **               **     **

  **     **               **     **               **     **

  **     **               **     **               **     **

  **     **               **     **               **     **

  **     **               **     **               **     **

  **     **               **     **               **     **

  **     **               **     **               **     **
  ----------------------- ----------------------- -----------------------

**[BUDGETING TIPS]{.underline}**

Please see budgeting tips for guidance. If you need additional
information on creating a budget, please contact Mark Pagano at x83-4292
or Tammy Capozzoli at x83-4266.

It is important to remember that this is an internal budget. Please do
not copy and paste. You need to determine that the VA is recovering the
costs of the procedures/services provided.

Investigational Drug Service is for the storage and dispensing of
Investigational Drugs or Devices. Any additional compounding or mixing
fees are additional and should be budgeted for on a per subject basis.

Consider any additional costs that you might incur and budget for them.

The costs of medical services are subject to increase or decrease each
Fiscal Year. If is recommended that you increase the actual cost of
procedures/services provided to cover increases for the duration of the
study.

If using off-site (outside of VAPHS) ancillary services (MRI or PET),
please contact the facility to determine the cost of this procedure and
budget accordingly.

If an off-site MD will be interpreting the imaging/procedure results,
you will need to verify the cost for this service and budget for it.