Date of Request:

Name of Requestor
(last, first):

Requestor's Phone #:

Requestor's Email Address:

Type of Manuscript:

Journal Book Abstract

Title of Manuscript:

Name(s) of Author(s) and Name(s) of Organization(s) (i.e. Smith, John, NICHD):

Publication to be Submitted to (Name of Journal/Book):

Abstract to be Presented at the (Name of Meeting):

Date of Meeting:

Location of Meeting:

Acknowledgement states "This research was supported [in part] by the Intramural Research Program of the NIH, [insert name of institute or institutes as well]" YES NO

Is this manuscript or abstract based on a Clinical Study Protocol? YES NO

Clinical Protocol number:

Clinical Exemption?

YES NO

Is this manuscript or abstract based on an Animal Study? YES NO

Animal Study number:

Title of CRADA that has Supported this Research:

Name of CRADA Partner:

Patentable?

Employee Invention Report filed Patent in Preparation Patent Filed Not Applicable

Newsworthy?

YES NO

Are Other Reviews (as Required by IC) Complete? YES NO

Dual Use Research

Is there the potential that your research findings, work product(s), processes or results could be readily misused to cause potential harm? YES NO
Consult the Dual Use Questionnaire to answer this question.

If yes, please submit this form along with the manuscript to your SD and to dualuse@mail.nih.gov

I will submit this article with a signed NIH Publishing Agreement & Manuscript Cover Sheet. If a peer-reviewed article, I will submit it to PubMedCentral upon acceptance for publication, unless the journal deposits the final published article directly in PMC (http://www.nihms.nih.gov). yes

Signature of NIH IC responsible author

Have all authors reviewed the attached manuscript or meeting abstract and accepted the content and the authorship? YES NO

Signature of the Lab or Branch Chief:

Date of Approval:

Signature of the Scientific Director or Designee:

Date of Approval: