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					                                        NEOMED SPONSORED PROJECTS INTERNAL ROUTING FORM
Directions: To assure on time delivery, the completed Routing Form and all required attachments must be
received by the Office of Research and Sponsored Programs at least ten (10) full business days prior to the due date. All
required attachments to this router may be found at: http://www.neomed.edu/research/office-of-research-and-sponsored-
programs/ORSP Routing Forms
                                                                                           PROPOSAL DEADLINE INFORMATION


                                                                             Submission Deadline:
                                                                             Submission Type:           Electronic          Hard Copy


                                                    PI/PD                              Co-PI                                    Co-Investigator*
                                Name:
Investigator




                        Department:
                               Phone:
                                E-mail:
                      *Add additional Co-Investigators to a Supplemental Sheet

                      Project Title:
                      Sponsor:
                      CFDA #:                                                        NIH Code (i.e. R01, R03, R15):
                      Award Type                   Proposal Type                     Agency Type                         Project Type
                        Research – Basic              New                               Federal                             Grant
Project Information




                        Research – Applied            Competitive Renewal               State                               Contract
                        Instructional                 Non-Competitive Renewal           Local                               Subaward appearing on
                        Public Service                Supplement                        Private Foundation                   another institution’s
                        Fellowship                    First Resubmission                Private Corporation                  application.
                        Other                         Second Resubmission               Association/Society                 Cooperative Agreement
                                                      Continuation                      Other                               Personal Service Agreement
                                                                                                                            Other
                      Will any part of this project be conducted outside of the NEOMED Rootstown campus?                   Yes      No
                      If Yes, please indicate the exact location:
                      Does this proposal contain post award subcontracts?                        Yes           No
                      Subcontract Institution:                                            PI on Subcontract:
                      Secondary Subcontract Institution:                                  PI on Secondary Subcontract:


                                                                          Project Performance Period

                      Initial Budget Period:           /    /       to           /    /                              Total Years:
Budget Information




                      Total Project Period:            /    /       to           /    /

                                       REQUESTED FROM SPONSOR                                                   COST SHARE BY NEOMED
                                          Direct                                                      Direct
                                                   Indirect Costs        Total                                               Indirect Costs            Total
                                          Costs                                                       Costs

                      Year 1        $              $                $                              $                    $                          $

                      Total for
                                    $              $                $                             $                     $                          $
                      all Years:

                         Form R07-008                           Last Revised 8/19/11                                                Page 1 of 3
                         Will this proposal consist of federal dollars awarded to another institution and passed through to NEOMED via a
                         grant or subcontract?         Yes       No      If Yes, please list the federal source:

                                                Cost Sharing                                                     Indirect Costs
                                                                                        Indirect Cost Rate Approved by NEOMED: 54%
                         Is Cost Sharing Proposed?      Yes     No
                                                                                        Indirect Cost Rate Permitted by Sponsor:
                         If Yes, Attach Cost Share Approval Form to this routing
                                                                                        Indirect Cost Rate for this Proposal:
                         form.
                         Cost Share is:     Required by Sponsor Voluntary               If Indirect Cost Rate is less than 54%, attach signed Request for
                         Will an additional party provide Cost Sharing?     Yes    No   Reduction or Waiver of Indirect Costs Form to this routing
                         If Yes, attach Authorization Letter from additional party      form.
                         stating their commitment to the project..



                         All personnel listed on this proposal must obtain permission from their Department Chair for the effort committed in this
                         proposal by completing a Proposal Time and Effort Form. Transfer effort percentages listed on the Time and Effort Form to
                         the spaces below:
Effort




                         Name                                    Funded Effort %                   Cost Share Effort %
                         Name                                    Funded Effort %                   Cost Share Effort %
                         Name                                    Funded Effort %                   Cost Share Effort %



                         It is the PI/PD’s responsibility to identify any of the
                         following compliance concerns contained in this project.                    Click here for Compliance Committee Applications
                         Failure to properly identify these concerns on this form will
                         delay the submission of your application for funding.
                         1. New Position at NEOMED. If funded, will this project involve hiring a new person(s)?               Yes        No

                         2. Human Subjects Research – Institutional Review Board (IRB)
                            Are you conducting a research project which includes interacting or intervening with individuals, obtaining information
                            about living individuals, or using human tissues or cell lines?      Yes      No          If no, go to #3
                            The status of this project with the IRB is:     Approved        Pending      Just-In-Time
                            If the protocol is approved or pending with the IRB, you must provide the protocol number:
                            If using human tissues/cells, are they publicly available from a source such as ATCC?       Yes       No
Compliance Information




                            If approval will be Just-In-Time, attach the Just-In-Time Approval Form for Use of Human Subjects to this router.

                         3. Vertebrate Animals- Institutional Animal Care and Use Committee (IACUC)
                            Does this project involve the use of vertebrate animals?       Yes     No       If no, go to #4
                            The status of this project with IACUC is:      Approved      Pending      Just-In-Time
                            If the protocol is approved or pending with the IACUC, you must provide the protocol number:
                            If approval will be Just-In-Time, attach the Just-In-Time Approval Form for Use of Animals to this router.

                         4. Radioisotopes- Radiation Safety Committee (RSC)
                           Does this project involve the use of radioisotopes?   Yes      No      If no, go to #5
                           If yes, attach the form Summary of Radioisotope Use for Grant Applications to this router.


                         5. Biological Safety- Institutional Biosafety Committee (IBC)
                            Does this project involve the use of recombinant DNA or other Biohazards Materials ( Bacteria, Fungi, Human Cells and
                            Tissues, Pathogenic Microorganisms, Parasites, Viruses, Prions, Mutagens, Carcinogens, Biological Toxins and cross-
                            breeding or creation of transgenic mice)          Yes   No            If No, go to next page.
                            If yes, is the use of the material approved by the IBC?  Yes      No If yes, you must list the approval/registration
                            number:
                             If you do not have an approval/registration number for use of the biohazardous material in this proposal, attach the
                            Summary of rDNA/Biohazard Usage Form to this router.
                           Form R07-008                          Last Revised 8/19/11                                       Page 2 of 3
          CERTIFICATIONS AND UNDERSTANDINGS OF PI AND DEPARTMENT CHAIR
    1. Conflict of Interest
        The Principal Investigator(s) and all key personnel certify they have read and understand NEOMED’s Conflict of
        Interest Policy and have completed and attached a Financial Disclosure Statement found within the policy;
        they have made all required disclosures as outlined in the Conflict of Interest Policy; and they will comply with any
        conditions or restrictions imposed by NEOMED to manage, reduce, or eliminate Conflict of Interest.
    2. Intellectual Property Policy
        The Principal Investigator(s) and all participants certify they have read and understand NEOMED’s Intellectual
        Property Policy.
    3. Debarment/Suspension
        The Principal Investigator and Co-Investigators, certify they are not debarred or suspended from doing business with
        the Federal Government. In addition, the Principal Investigator certifies that any subcontractors listed on the
        proposal are not debarred or suspended. A list of all entities, firms, and individuals currently debarred from doing
        business can be found at https://epls.gov .
    4. Human Subjects Training
        The Principal Investigator and Co-Investigators certify that they have completed all required Human Subjects Training
        if applicable. Training certificates older than 3 years will not be accepted. http://phrp.nihtraining.com/
    5. Understandings:
        a) If an award is made, I understand that I am responsible for the scientific conduct of the project and will comply
        with award terms and conditions, as well as institutional policies and procedures; for the technical conduct of the
        work; submission of required progress reports and technical reports; regulatory compliance; and the management of
        funds awarded.
        b) The proposed budget includes all the cost sharing, necessary equipment, installation, shipping, new space,
        renovation and/or facility modification costs associated with this project. I do not expect the Institution to assume
        any of these costs with the exception of those included and approved by the Department Chair on this application
        (i.e., Cost Sharing).
        c) By my signature below, I am attesting that the information contained on this form and within this application is
        true, accurate, and complete. I understand that any false, fictitious, or fraudulent statements/claims made by me
        may subject me to criminal, civil, or administrative penalties.
        Principal Investigator:                                        Date:

        Principal Investigator:                                        Date: __________________________

        Co-Investigator:                                               Date:

        Co-Investigator:                                                 Date:
   6. For all NIH Proposals:
       The NIH requires the following statement be signed and retained by the Institution for all NIH applicants:
       I certify that the statements of this proposal are true, complete, and accurate to the best of my 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 proposal. I also agree to comply with the NIH Public Access Policy.

        Principal Investigator:                                        Date:
The Department Chair’s signature on this form assures to the Vice President for Research that:
The PI/PD has proposed a project that responds to the objectives of the department; the PI/PD has the available time to
commit to the project and a signed Time and Effort Form has been completed and attached to this router; the departmental
commitments in the application have been approved including, but not limited to, cost sharing . A Cost Share Form has been
signed and attached to this router if applicable; All personnel listed on this router have completed and signed a Conflict of
Interest Disclosure Form and attached.
        Department Chair:                                               Date:

        Department Chair:                                               Date: _____________________________

        Department Chair:                                               Date: _____________________________



  Form R07-008                           Last Revised 8/19/11                                      Page 3 of 3

				
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