Enter Subcontract/Consortium Total Costs for Each Year
Year 1 Year 2 Year 3 Year 4 Year 5 Total
Subcontract 1 Direct Costs 0
Subcontract 1 Indirect Costs 0
Subcontract 2 Direct Costs 0
Subcontract 2 Indirect Costs 0
Subcontract 3 Direct Costs 0
Subcontract 3 Indirect Costs 0
Subcontract 4 Direct Costs 0
Subcontract 4 Indirect Costs 0
Subcontract 5 Direct Costs 0
Subcontract 5 Indirect Costs 0
- - - - -
- - - - -
Subcontract 1 - - - - - -
Subcontract 2 - - - - - -
Subcontract 3 - - - - - -
Subcontract 4 - - - - - -
Subcontract 5 - - - - - -
- - - - - -
Calculates indirect costs on the first $25,000 for each subaward.
Sub 1 Sub 2 Sub 3 Sub 4 Sub 5
Cummulative Total Costs Year 1 - - - - -
Year 2 - - - - -
Year 3 - - - - -
Year 4 - - - - -
Year 5 - - - - -
MTDC Base Each Year Year 1 - - - - -
for each Subcontract Year 2 - - - - -
Year 3 - - - - -
Year 4 - - - - -
Year 5 - - - - -
MTDC Base Each Year Year 1 Year 2 Year 3 Year 4 Year 5
- - - - -
TO PRINT SPREADSHEET, SELECT OPTION:
ON:
● Form Approved Through 05/2004
OMB No. 0925-0001
Department of Health and Human Services LEAVE BLANK--FOR PHS USE ONLY.
Public Health Service
Grant Application
Follow instructions carefully.
Do not exceed 56-character length restrictions, including spaces.
1. TITLE OF PROJECT
2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION No Yes
(If "Yes," state number and title)
Number: Title:
3. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR New Investigator No Yes
3a. NAME (Last, first, middle) 3b. DEGREE(S)
3d. POSITION TITLE 3e. MAILING ADDRESS (Street, city, state, zip code)
3f. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3g. MAJOR SUBDIVISION
3h. TELEPHONE AND FAX (Area code, number and extension) E-MAIL ADDRESS:
TEL: (716) FAX: (716)
4. HUMAN 4a. Research Exempt No Yes
5. VERTEBRATE ANIMALS No Yes
SUBJECTS If "Yes," Exemption Number
No 4b. Human Subjects Assurance 4c. NIH-defined Phase III Clinical 5a. If "Yes," IACUC approval Date 5b. Animal welfare assurance no.
Yes No. Trial
No Yes
6. DATES OF PROPOSED PERIOD OF 7. COSTS REQUESTED FOR INITIAL 8. COSTS REQUESTED FOR PROPOSED
SUPPORT (month, day, year-MM/DD/YY) BUDGET PERIOD PERIOD OF SUPPORT
From Through 7a. Direct Costs ($) 7b.Total Costs ($) 8a. Direct Costs ($) 8b. Total Costs ($)
0. 0. 0. 0.
9. APPLICANT ORGANIZATION 10. TYPE OF ORGANIZATION
Name The Research Foundation of State University of New York Public: Federal State Local
Address on behalf of University at Buffalo Private: X Private Nonprofit
The UB Commons, Suite 211 Forprofit: General Small Business
520 Lee Entrance Women-owned Socially and Economically Disadvantaged
Amherst, NY 14228-2567 11. ENTITY IDENTIFICATION NUMBER
1146013200F6
DUNS NO. (if available)
02-06-57151
Institutional Profile File Number (if known): Congressional District 27th
12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE 13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name Dr. Charles Kaars Name
Title Assistant Vice President Title Grant & Contract Administrator
Address Sponsored Programs Administration Address Sponsored Programs Administration
The UB Commons, Suite 211 The UB Commons, Suite 211
520 Lee Entrance 520 Lee Entrance
Amherst, NY 14228-2567 Amherst, NY 14228-2567
Telephone (716) 645-2977 Phone (716) 645-2977
FAX (716) 645-3730 FAX (716) 645-3730
E-Mail awards@research.buffalo.edu E-Mail @research.buffalo.edu
15. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE: SIGNATURE OF PI/PD NAMED IN 3a. DATE
I certify that the statements herein are true, complete and accurate to the best of my (In ink. "Per" signature not acceptable.)
knowledge. I am aware that any false, fictitious, or fraudulent statements or claims may subject
me to criminal, civil, or administrative penalties. I agree to accept responsibility for the scientific
conduct of the project and to provide the required progress reports if a grant is awarded as a
result of this application.
16. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: SIGNATURE OF OFFICIAL NAMED IN 13. DATE
I certify that the statements herein are true, complete and accurate to the best of my (In ink. "Per" signature not acceptable.)
knowledge, and accept the obligation to comply with Public Health Service terms and
conditions if a grant is awarded as a result of this application. I am aware that any false,
fictitious, or fraudulent statements or claims may subject me to criminal, civil, or
administrative penalties.
PHS 398 (Rev. 5/01) Face Page Form Page 1
● Principal Investigator/Program Director (Last, first, middle):
FROM THROUGH
DETAILED BUDGET FOR INITIAL BUDGET PERIOD
DIRECT COSTS ONLY
%
PERSONNEL (Applicant Organization Only) DOLLAR AMOUNT REQUESTED (omit cents)
TYPE EFFORT
ROLE APPT. ON INST. BASE SALARY FRINGE
NAME ON PROJECT (months) PROJ. SALARY REQUESTED BENEFITS TOTAL
Principal
Investigator
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTS INPATIENT
OUTPATIENT
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
Tuition: Participant support costs:
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD
CONSORTIUM/CONTRACTUAL DIRECT COSTS
COSTS FACILITIES AND ADMINISTRATION COSTS
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)
SBIR/STTR Only: FIXED FEE REQUESTED
PHS 398 (Rev. 5/01) Page _____ Form Page 4
Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 3a, 35b.
● Principal Investigator/Program Director (Last, first, middle):
FROM THROUGH
DETAIL ED B UDGET FOR INITIAL B UDGET PERIOD
DIRECT COSTS ONL Y 12/31/00 12/30/01
%
PERSONNEL (Applicant Organization Only) DOLLAR AMOUNT REQUESTED (omit cents)
TYPE EFFORT
ROLE ON APPT. ON INST. BASE SALARY FRINGE
NAME PROJECT (months) PROJ SALARY REQUESTED BENEFITS TOTAL
Principal
Investigator
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTS INPATIENT
OUTPATIENT
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
Tuition: Participant support costs:
SUB TOTAL DIRECT COSTS FOR INITIAL B UDGET PERIOD
CONSORTIUM/CONTRACTUAL DIRECT COSTS
COSTS FACILITIES AND ADMINISTRATION COSTS
TOTAL DIRECT COSTS FOR INITIAL B UDGET PERIOD (Item 7a, Face Page)
SB IR/STTR On ly: FIXED FEE REQUESTED
PHS 398 (Rev. 5/01) Page _____ Form Page 4
Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 3a, 35b..
● Principal Investigator/Program Director (Last, first, middle):
FROM THROUGH
DETAIL ED B UDGET FOR INITIAL B UDGET PERIOD
DIRECT COSTS ONL Y 12/31/01 12/30/02
%
PERSONNEL (Applicant Organization Only) DOLLAR AMOUNT REQUESTED (omit cents)
TYPE EFFORT
ROLE APPT. ON INST. BASE SALARY FRINGE
NAME ON PROJECT (months) PROJ SALARY REQUESTED BENEFITS TOTAL
Principal
Investigator
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTS INPATIENT
OUTPATIENT
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
Tuition: Participant support costs:
SUB TOTAL DIRECT COSTS FOR INITIAL B UDGET PERIOD
CONSORTIUM/CONTRACTUAL DIRECT COSTS
COSTS FACILITIES AND ADMINISTRATION COSTS
TOTAL DIRECT COSTS FOR INITIAL B UDGET PERIOD (Item 7a, Face Page)
SB IR/STTR On ly: FIXED FEE REQUESTED
PHS 398 (Rev. 5/01) Page _____ Form Page 4
Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 3a, 35b..
● Principal Investigator/Program Director (Last, first, middle):
FROM THROUGH
DETAIL ED B UDGET FOR INITIAL B UDGET PERIOD
DIRECT COSTS ONL Y 12/31/02 12/30/03
%
PERSONNEL (Applicant Organization Only) DOLLAR AMOUNT REQUESTED (omit cents)
TYPE EFFORT
ROLE APPT. ON INST. BASE SALARY FRINGE
NAME ON PROJECT (months) PROJ SALARY REQUESTED BENEFITS TOTAL
Principal
Investigator
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTS INPATIENT
OUTPATIENT
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
Tuition: Participant support costs:
SUB TOTAL DIRECT COSTS FOR INITIAL B UDGET PERIOD
CONSORTIUM/CONTRACTUAL DIRECT COSTS
COSTS FACILITIES AND ADMINISTRATION COSTS
TOTAL DIRECT COSTS FOR INITIAL B UDGET PERIOD (Item 7a, Face Page)
SB IR/STTR On ly: FIXED FEE REQUESTED
PHS 398 (Rev. 5/01) Page _____ Form Page 4
Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 3a, 35b..
● Principal Investigator/Program Director (Last, first, middle):
FROM THROUGH
DETAILED BUDGET FOR INITIAL BUDGET PERIOD
DIRECT COSTS ONLY 12/31/03 12/30/04
PERSONNEL (Applicant Organization Only) DOLLAR AMOUNT REQUESTED (omit cents)
TYPE %
ROLE APPT. EFFORT INST. BASE SALARY FRINGE
NAME ON PROJECT (months) ON PROJ SALARY REQUESTED BENEFITS TOTAL
Principal
Investigator
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTS INPATIENT
OUTPATIENT
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
Tuition: Participant support costs:
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD
CONSORTIUM/CONTRACTUAL DIRECT COSTS
COSTS FACILITIES AND ADMINISTRATION COSTS
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)
SBIR/STTR Only: FIXED FEE REQUESTED
PHS 398 (Rev. 5/01) Page _____ Form Page 4
Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 3a, 35b..
● Principal Investigator/Program Director (Last, first, middle):
BUDGET FOR ENTIRE PROPOSED PERIOD OF SUPPORT
DIRECT COSTS ONLY
INITIAL BUDGET ADDITIONAL YEARS OF SUPPORT REQUESTED
BUDGET CATEGORY PERIOD
TOTALS (from Form Page 4) 2nd 3rd 4th 5th
PERSONNEL: Salary and fringe benefits.
Applicant organization only.
CONSULTANT COSTS
EQUIPMENT
SUPPLIES
TRAVEL
INPATIENT
PATIENT CARE COSTS
OUTPATIENT
ALTERATIONS AND
RENOVATIONS
OTHER EXPENSES
SUBTOTAL DIRECT COSTS
CONSORTIUM/ DIRECT
CONTRACTUAL COSTS
F&A
TOTAL DIRECT COSTS
TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PERIOD OF SUPPORT (Item 8a, Face Page)
SBIR/STTR Only Fixed Fee Requested
SBIR/STTR Only: Total Fixed Fee Requested for Entire Proposed Phase II Period (Add total Fixed Fee amount to
"Total direct costs for entire period" above and Total F&A/Indirect costs from Checklist Form Page, and enter these as
"Costs Requested for Propos
JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.
PHS 398 (Rev. 5/01) Page _____ Form Page 5
Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 3a, 35b..
● Principle Investigator/Program Director (Last, first, middle):
FROM THROUGH
SCHEDULE OF ADDITIONAL PERSONNEL
(NOT FITTING ON THE NIH FORM)
PERSONNEL (Applicant Organization Only) INST. DOLLAR AMOUNT REQUESTED (omit cents)
ROLE TYPE APPT. % EFFORT ON BASE SALARY FRINGE
NAME ON PROJECT (months) PROJ SALARY REQUESTED BENEFITS TOTAL
INDIRECT COST SCHEDULE - MODULAR GRANT
FOR PROJECT STARTING ON:
DHHS Agreement Dated 6/14/01
PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR:
INDIRECT COST INDIRECT COST
BASE RATE INDIRECT COST
FIRST YEAR x 0 =
SECOND YEAR x 55.00 =
THIRD YEAR x 55.00 =
FOURTH YEAR x 55.00 =
FIFTH YEAR x 55.00 =
TOTAL
INDIRECT COST SCHEDULE - NONMODULAR GRANT
FOR PROJECT STARTING ON:
DHHS Agreement Dated 6/14/01
PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR:
INDIRECT COST INDIRECT COST
BASE RATE INDIRECT COST
FIRST YEAR x 0 =
SECOND YEAR x 55.00 =
THIRD YEAR x 55.00 =
FOURTH YEAR x 55.00 =
FIFTH YEAR x 55.00 =
TOTAL
12/3/2011
● Principal Investigator/Program Director (Last, first, middle):
CHECKLIST
TYPE OF APPLICATION (Check all that apply.)
NEW application. (This application is being submitted to the PHS for the first time.)
SBIR Phase I SBIR Phase II: SBIR Phase I Grant No. SBIR Fast Track
STTR Phase I STTR Phase II: STTR Phase I Grant No. STTR Fast Track
REVISION of application number:
(This application replaces a prior unfunded version of a new, competing continuation, or supplemental application.)
INVENTIONS AND PATENTS (Competing continuation appl. only)
COMPETING CONTINUATION of grant number: No Previously reported
(This application is to extend a funded grant beyond its current project period.) Yes. If "Yes," Not previously reported
SUPPLEMENT to grant number:
(This application is for additional funds to supplement a currently funded grant.)
CHANGE of principal investigator/program director.
Name of former principal investigator/program director:
FOREIGN application or significant foreign component.
1. PROGRAM INCOME (See instructions.)
All applications must indicate whether program income is anticipated during the period(s) for which grant support is requested. If program income is
anticipated, use the format below to reflect the amount and source(s).
Budget Period Anticipated Amount Source(s)
2. ASSURANCES/CERTIFICATIONS (See instructions.)
The following assurances/certifications are made and verified by the signature of the -Debarment and Suspension; -Drug- Free Workplace (applicable to new [Type 1] or
Official Signing for Applicant Organization on the Face Page of the application. revised [Type 1] applications only); - Lobbying; -Non-Delinquency on Federal Debt; -
Descriptions of individual assurances/certifications are provided in Section III. If Research Misconduct; -Civil Rights (Form HHS441 or HHS 690); -Handicapped
unable to certify compliance where applicable, provide an explanation and place it Individuals (Form HHS 641 or HHS 690); -Sex Discrimination (Form HHS 639-A or
after this page. HHS 690); -Age Discrimination (Form HHS 680 or HHS 690); -Recombinant DNA and
-Human Subjects; -Research Using Human Pluripotent Stem Cells Human Gene Transfer Research; -Financial Conflict of Interest (except Phase I
-Research on Transplantation of Human Fetal Tissue -Women and SBIR/STTR)
Minority Inclusion Policy -Inclusion of Children Policy -Vertebrate Animals; STTR ONLY: Certification of Research Institution Participation.
3. FACILITIES AND ADMINISTRATIVE COSTS (F&A)/ INDIRECT COSTS. See specific instructions.
X DHHS Agreement dated: 06/14/01 No Facilities And Administration Cost Requested.
DHHS Agreement being negotiated with Regional Office
No DHHS Agreement, but rate established with Date
CALCULATION* (The entire grant application, including the Checklist, will be reproduced and provided to peer reviewers as confidential information.
Supplying the following information on indirect costs is optional for forprofit organizations.)
a. Initial budget period: Amount of base: $ x Rate applied 0 % = F & A costs $
b. 02 year Amount of base: $ x Rate applied 55.00 % = F & A costs $
c. 03 year Amount of base: $ x Rate applied 55.00 % = F & A costs $
d. 04 year Amount of base: $ x Rate applied 55.00 % = F & A costs $
e. 05 year Amount of base: $ x Rate applied 55.00 % = F & A costs $
TOTAL F&A Costs $
*Check appropriate box(es):
Salary and wages base X Modified total direct cost base Other base (Explain)
X Off-site, other special rate, or more than one rate involved (Explain)
Explanation (Attach separate sheet, if necessary.) : Per F&A agreement, on-campus research rate increases to 57% as of 7/1/03.
4. SMOKE-FREE WORKPLACE Yes No (The response to this question has no impact on review or funding of this application.)
PHS 398 (Rev. 05/01) Page Checklist Form Page
Modules
Modules
Principal Investigator: 0
Year One Year Two Year Three Year Four Year Five Total
Total Direct Costs from 398 Form $0 $0 $0 $0 $0 $0
Number of Years 1
Option 1 -- Total Direct Costs Rounded up to the Nearest Multiple of $25,000 x number of years.
Rounded Total $0
Modules Per Year 0 0 0 0 0 0
Modular TDC per Year $0 $0 $0 $0 $0 $0
Difference btwn. Modules & 398 $0 $0 $0 $0 $0 $0
% Difference #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Option 2 -- Total Direct Costs Rounded down to the Nearest Multiple of $25,000 x number of years.
Modules Per Year -1 0 0 0 0 -1
Modular TDC per Year -$25,000 $0 $0 $0 $0 -$25,000
Difference btwn. Modules & 398 -$25,000 $0 $0 $0 $0 -$25,000
% Difference #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
YOUR REQUEST: PLEASE ENTER IN THIS SECTION THE MODULES THAT YOU WILL REQUEST FOR EACH YEAR.
Please Note: In order for the IDC page and Justification page to calculate correctly, the modules you will request
must be entered in this section.
If you request a different number of modules in any year it must be for specific costs to that year and
must be fully justified in the "Budget Justification Form".
Modules Per Year -
Modular TDC per Year - - - - - -
Difference btwn. Modules & 398 $0 $0 $0 $0 $0 $0
% Difference #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
12/3/2011
Data for Justification Page
Total Direct Costs for Entire Proposed Period of Support: $ -
Initial Budget Second Year of Third Year of Fourth Year of Fifth Year of
Period Support Support Support Support
$ - $ - $ - $ - $ - -
Personnel The Following Personnel are taken from the "Year 1" budget page.
0 Principal Investigator 0%
0 0 0%
0 0 0%
0 0 0%
0 0 0%
0 0 0%
0 0 0%
0 0 0%
0 0 0%
0 0%
0 0 0%
0 0 0%
0 0 0%
0 0 0%
0 0 0%
Equipment NOTE: Include equipment on the justification ONLY if it results in
an increased number of modules in any year.
0 - 0 -
0 - 0 -
0 - 0 -
Consortium
Approximately $ - Total Costs for all years.