PHS 398 Budget Template by pqhJNdjb

VIEWS: 20 PAGES: 15

									                                                                                Initial Budget
PERSONNEL                                                                                                                                                              Reference Table
                                                             Student and/or    Calendar        Inst. Base       Requested           Fringe                              Salary       $0-   $64,501- $79,501- $105,001- $141,001- $173,501-                         $0-
             Name                   Role on Project                                                                                                     Total                                                                              $245,001-   Student
                                                            Part-time Position Months            Salary           Salary           Benefits                              Cap       $64,500 $79,500 $105,000 $141,000 $173,500 $245,000                           $51,000
                                   Principal Investigator                        0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
                                                                                 0.00                   $0               $0                   $0                 $0     $179,700   32.98%   26.31%   24.43%     21.99%    20.27%    18.32%    14.47%   FALSE      23.05%   23.05%
Subtotals                                                                                                                  $0                 $0                 $0

CONSULTANT
                                                                                                                                                                 $0
                                                                                                                                                                 $0
Total                                                                                                                                                            $0

EQUIPMENT
                                                                                                                                                                 $0
                                                                                                                                                                 $0
Total                                                                                                                                                            $0

SUPPLIES
                                                                                                                                                                 $0
                                                                                                                                                                 $0
                                                                                                                                                                 $0
                                                                                                                                                                 $0
                                                                                                                                                                 $0
Total                                                                                                                                                            $0

TRAVEL
                                                                                                                                                                 $0
                                                                                                                                                                 $0
Total                                                                                                                                                            $0

PATIENT CARE COSTS
              INPATIENT                                                                                                                                          $0
            OUTPATIENT                                                                                                                                           $0
Total                                                                                                                                                            $0

ALTERATIONS & RENOVATIONS
                                                                                                                                                                 $0
                                                                                                                                                                 $0
Total                                                                                                                                                            $0

OTHER EXPENSES
                                                                                                                                                                 $0                                                                                    FALSE           0
                                                                                 Please check the box if the item should be
                                                                                                                                                                 $0                                                                                    FALSE           0
                                                                                 excluded from the indirect cost base (ex: tuition
                                                                                                                                                                 $0                                                                                    FALSE           0
                                                                                 remission, off-site facilities rental, scholarships,
                                                                                                                                                                 $0                                                                                    FALSE           0
                                                                                 fellowships, etc.)
                                                                                                                                                                 $0                                                                                    FALSE           0
Total                                                                                                                                                            $0                                                                                                    0

                                                                                           Subtotal Direct Costs for Initial Budget Period                       $0

Consortium 1                                                                               Direct                                                                $0
                                                                                           Indirect            Indirect Rate =           0.00%                   $0

Consortium 2                                                                               Direct                                                                $0
                                                                                           Indirect            Indirect Rate =           0.00%                   $0

Consortium 3                                                                               Direct                                                                $0
                                                                                           Indirect            Indirect Rate =           0.00%                   $0

                                                                                              Total Direct Costs for Initial Budget Period                       $0



                                          Budget for Entire Proposal Period - With 2% Cost of Living Increase
                                     Initial Budget
            Category                                                   2nd                       3rd                 4th              5th               Total
                                         Period
PERSONNEL                                             $0                              $0                 $0                $0                 $0                 $0
CONSULTANT                                            $0                              $0                 $0                $0                 $0                 $0
EQUIPMENT                                             $0                              $0                 $0                $0                 $0                 $0
SUPPLIES                                              $0                              $0                 $0                $0                 $0                 $0
TRAVEL                                                $0                              $0                 $0                $0                 $0                 $0
INPATIENT COSTS                                       $0                              $0                 $0                $0                 $0                 $0
OUTPATIENT COSTS                                      $0                              $0                 $0                $0                 $0                 $0
ALT. & RENOVATIONS                                    $0                              $0                 $0                $0                 $0                 $0
OTHER EXPENSES                                        $0                              $0                 $0                $0                 $0                 $0
Subtotal Direct Cost                                  $0                              $0                 $0                $0                 $0                 $0

Consortium 1 Direct Costs                            $0                               $0                  $0               $0                $0                  $0
Indirect Cost Rate                               0.00%                            0.00%               0.00%            0.00%             0.00%
Consortium 1 Indirect Costs                          $0                               $0                  $0               $0                $0                  $0
Total Cost - Consortium 1                             $0                              $0                 $0                $0                 $0                 $0

Consortium 2 Direct Costs                            $0                               $0                  $0               $0                $0                  $0
Indirect Cost Rate                               0.00%                            0.00%               0.00%            0.00%             0.00%
Consortium 2 Indirect Costs                          $0                               $0                  $0               $0                $0                  $0
Total Cost - Consortium 2                             $0                              $0                 $0                $0                 $0                 $0

Consortium 3 Direct Costs                            $0                               $0                  $0               $0                $0                  $0
Indirect Cost Rate                               0.00%                            0.00%               0.00%            0.00%             0.00%
Consortium 3 Indirect Costs                          $0                               $0                  $0               $0                $0                  $0
Total Cost - Consortium 3                             $0                              $0                 $0                $0                 $0                 $0

Total Direct Costs                                    $0                              $0                 $0                $0                 $0                 $0

Applicants must seek agreement to accept assignment from Institute/Center staff at least six weeks prior to the anticipated submission of any application (including
     PPGs) requesting $500,000 or more in direct costs for any year exclusive of any consortium F&A costs. For additional information, please NIH's 398
                                                                Instructions (Part III, Policies).

                                                                    Modular Grant Budgets                                                                               Modular
   Check box to use Modular formatting and choose between the two options below                                                                      FALSE

        Convert direct costs into modular format with equal modules (divides total direct costs by # of budget periods)                                      1
Equal Modules                                                                                                                           Total
Modular Direct Cost                         $0                         $0                  $0              $0                     $0            $0


         Convert direct costs into modular format with variable modules (independently calculates each budget period)
Variable Modules                                                                                                                        Total
Modular Direct Cost                          $0                         $0               $0              $0                       $0            $0




                                               F&A Cost Base Calculations                                                               Total
       Subtotal Direct Cost                   $0                         $0                      $0               $0              $0            $0
          Minus Equipment                     $0                         $0                      $0               $0              $0            $0
      Minus InPatient Costs                   $0                         $0                      $0               $0              $0            $0
    Minus OutPatient Costs                    $0                         $0                      $0               $0              $0            $0
   Minus Alt. & Renovations                   $0                         $0                      $0               $0              $0            $0
   Minus Other (tuition, etc.)                $0                         $0                      $0               $0              $0            $0
             Subtotal MTDC                    $0                         $0                      $0               $0              $0            $0
                                    Consortium Costs Up to $25,000 for each Subcontract
         Plus Consortium 1*                   $0                         $0                      $0               $0              $0            $0
         Plus Consortium 2*                   $0                         $0                      $0               $0              $0            $0
         Plus Consortium 3*                   $0                         $0                      $0               $0              $0            $0
           Total MTDC Base                    $0                         $0                      $0               $0              $0            $0

                                                                                                                                        Total
      Total Consortium F&A                       $0                            $0                $0               $0              $0            $0

    Current UTMB F&A Rate                   53.00%                         53.00%            53.00%           53.00%           53.00%   Total
            Total F&A Costs                      $0                            $0                $0               $0              $0            $0

                                                                                                                                        Total
Total Costs (Direct & F&A )                      $0                            $0                $0               $0              $0            $0



                           Template created by Jennifer Martin Rider for the Office of Sponsored Programs. Updated 1/10/2012
                                  For questions about this template please call 409-266-9400 or email: ehuff@utmb.edu
Form Approved Through 6/30/2012                                                                                                                             OMB No. 0925-0001
                      Department of Health and Human Services                                      LEAVE BLANK—FOR PHS USE ONLY.
                              Public Health Services                                               Type         Activity      Number
                                                                                                   Review Group               Formerly
                            Grant Application
                                                                                                   Council/Board (Month, Year)                  Date Received
                 Do not exceed character length restrictions indicated.
1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation.)


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
3a. NAME (Last, first, middle)                                                                     3b. DEGREE(S)                          3h. eRA Commons User Name


3c. POSITION TITLE                                                                                 3d. MAILING ADDRESS (Street, city, state, zip code)


3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT                                                                   The University of Texas Medical Branch
                                                                                                                     301 University Blvd.
3f. MAJOR SUBDIVISION                                                                                                Galveston, Texas 77555

3g. TELEPHONE AND FAX (Area code, number and extension)                                            E-MAIL ADDRESS:
TEL:                                                FAX:
4. HUMAN SUBJECTS RESEARCH                                   4a. Research Exempt                   If "Yes," Exemption No.
        No         Yes                                           No       Yes
4b. Federal-Wide Assurance No.                               4c. Clinical Trial                                              4d. NIH-defined Phase III Clinical Trial
                  FWA00002729                                    No        Yes                                                   No       Yes
5. VERTEBRATE ANIMALS       No     Yes                                                             5a. Animal Welfare Assurance No.                       A3314-01
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 ($)          8b. Total Costs ($)



9. APPLICANT ORGANIZATION                                                                          10. TYPE OF ORGANIZATION
Name              The University of Texas Medical Branch                                                   Public:              Federal          State          Local
Address           301 University Blvd.                                                                     Private:             Private Nonprofit

                  Galveston, Texas 77555                                                                   For-profit:         General          Small Business

                                                                                                          Woman-owned            Socially and Economically Disadvantaged
                                                                                                   11. ENTITY IDENTIFICATION NUMBER
                                                                                                   1746000949A1
                                                                                                   DUNS NO. 800771149            Cong. District  TX-014
12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE                                        13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name              Toni D'Agostino                                                                  Name              Connie J. Barton
Title             Director, Office of Sponsored Programs                                           Title             Assoc. Director, Office of Sponsored Prog.
Address           301 University Blvd.                                                             Address           301 University Blvd.
                  Galveston, Texas 77555-0156                                                                        Galveston, Texas 77555-0156


Tel:              (409) 266-9400                  FAX:       (409) 266-9469                        Tel:              (409) 266-9400                FAX:   (409) 266-9469

E-Mail:           sponsored.research@utmb.edu                                                      E-Mail:      sponsored.research@utmb.edu
15. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that                            SIGNATURE OF OFFICIAL NAMED IN 13.                              DATE
the statements herein are true, complete and accurate to the best of my knowledge, and             (In ink. "Per" signature not acceptable.)
accept the obligation to comply with Public Health Services 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. 6/09)                                                                Face Page                                                                       Form Page 1
. 0925-0001
         Principal Investigator/Program Director (Last, First, Middle):
             DETAILED BUDGET FOR INITIAL BUDGET PERIOD                                            FROM                 THROUGH

                        DIRECT COSTS ONLY
List PERSONNEL (Applicant organization only)
Use Cal, Acad, or Summer to Enter Months Devoted to Project
Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits
                                       ROLE ON           Cal.     Acad.     Sum. INST.BASE    SALARY            FRINGE
               NAME                    PROJECT          Mnths    Mnths     Mnths     SALARY REQUESTED          BENEFITS      TOTAL

                                            PD/PI




                                      SUBTOTALS
CONSULTANT COSTS


EQUIPMENT (Itemize)




SUPPLIES (Itemize by category)




TRAVEL


INPATIENT CARE COSTS
OUTPATIENT CARE COSTS
ALTERATIONS AND RENOVATIONS (Itemize by category)


OTHER EXPENSES (Itemize by category)




CONSORTIUM/CONTRACTUAL COSTS                                                                          DIRECT COSTS

SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a face page)                                                     $
CONSORTIUM/CONTRACTUAL COSTS                                                     FACILITIES AND ADMINISTRATIVE COSTS

TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD                                                                            $
PHS 398 (Rev. 6/09)                                                       Page                                              Form Page 4
               Principal Investigator/Program Director (Last, First, Middle):

            DETAILED BUDGET FOR INITIAL BUDGET PERIOD                                            FROM                 THROUGH

                       DIRECT COSTS ONLY
List PERSONNEL (Applicant organization only)
Use Cal, Acad, or Summer to Enter Months Devoted to Project
Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits

                                         ROLE ON           Cal.      Acad.      Sum.    INST.BASE  SALARY     FRINGE
              NAME                       PROJECT          Mnths      Mnths      Mnths     SALARY REQUESTED   BENEFITS       TOTAL




                                      SUBTOTALS
CONSULTANT COSTS


EQUIPMENT (Itemize)




SUPPLIES (Itemize by category)




TRAVEL


INPATIENT CARE COSTS
OUTPATIENT CARE COSTS
ALTERATIONS AND RENOVATIONS (Itemize by category)


OTHER EXPENSES (Itemize by category)




CONSORTIUM/CONTRACTUAL COSTS                                                                         DIRECT COSTS

SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (item 7a face page)                                                    $
CONSORTIUM/CONTRACTUAL COSTS                                                    FACILITIES AND ADMINISTRATIVE COSTS

TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD                                                                           $
PHS 398 (Rev. 6/09)                                                    Page                                                Form Page 4
               Principal Investigator/Program Director (Last, First, Middle):

            DETAILED BUDGET FOR INITIAL BUDGET PERIOD                                            FROM                 THROUGH

                       DIRECT COSTS ONLY
List PERSONNEL (Applicant organization only)
Use Cal, Acad, or Summer to Enter Months Devoted to Project
Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits

                                         ROLE ON           Cal.      Acad.      Sum.    INST.BASE  SALARY      FRINGE
              NAME                       PROJECT          Mnths      Mnths      Mnths     SALARY REQUESTED    BENEFITS      TOTAL




                                      SUBTOTALS
CONSULTANT COSTS


EQUIPMENT (Itemize)




SUPPLIES (Itemize by category)




TRAVEL


INPATIENT CARE COSTS
OUTPATIENT CARE COSTS
ALTERATIONS AND RENOVATIONS (Itemize by category)


OTHER EXPENSES (Itemize by category)




CONSORTIUM/CONTRACTUAL COSTS                                                                         DIRECT COSTS

SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (item 7a face page)                                                    $
CONSORTIUM/CONTRACTUAL COSTS                                                    FACILITIES AND ADMINISTRATIVE COSTS

TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD                                                                           $
PHS 398 (Rev. 6/09)                                                    Page                                                Form Page 4
                       Principal Investigator/Program Director (Last, first, middle):

                                   BUDGET FOR ENTIRE PROPOSED PROJECT PERIOD
                                               DIRECT COSTS ONLY
                                      INITIAL BUDGET          2nd ADDITIONAL             3rd ADDITIONAL  4th ADDITIONAL   5th ADDITIONAL
      BUDGET CATEGORY
                                          PERIOD             YEAR OF SUPPORT            YEAR OF SUPPORT YEAR OF SUPPORT       YEAR OF
          TOTALS
                                     (from Form Page 4)         REQUESTED                  REQUESTED       REQUESTED         SUPPORT
PERSONNEL: Salary and fringe
benefits. Applicant organization
only.

CONSULTANT COSTS


EQUIPMENT


SUPPLIES


TRAVEL


INPATIENT CARE COSTS


OUTPATIENT CARE COSTS

ALTERATIONS AND
RENOVATIONS

OTHER EXPENSES

DIRECT CONSORTIUM/
CONTRACTUAL COSTS

SUBTOTAL DIRECT COSTS
(Sum = Item 8a, Face Page)

F&A CONSORTIUM/
CONTRACTUAL COSTS

TOTAL DIRECT COSTS

TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD                                                                     $
JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.




 PHS 398 (Rev. 6/09)                                                           Page                                           Form Page 5
          Principal Investigator/Program Director (Last, First, Middle):

                                             BUDGET JUSTIFICATION PAGE
                                         MODULAR RESEARCH GRANT APPLICATION
                                                                                                                 Sum Total
                                        Initial Period              2nd            3rd           4th   5th   (For Entire Project
                                                                                                                   Period)

DC less Consortium F&A
                                     (Item 7a, Face Page)                                                    (Item 8a, Face Page)

Consortium F&A

Total Direct Costs

Personnel




Equipment




Consortium
Approximately $                         Total Costs for all years
Consortium with                                                     { } Domestic   { } Foreign
           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.)
      RESUBMISSION of application number:
      (This application replaces a prior unfunded version of a new, renewal, or revision application.)

     RENEWAL of grant number:
     (This application is to extend a funded grant beyond its current project period.)

     REVISION to grant number:
     (This application is for additional funds to supplement a currently funded grant.)
     CHANGE of program director/principal investigator.
      Name of former program director/principal investigator:
     CHANGE of Grantee Institution. Name of former institution:

     FOREIGN application              Domestic Grant with foreign involvement             List Country(ies)
                                                                                          Involved:
INVENTIONS AND PATENTS (Renewal appl. Only)                      No           Yes

                                                                           If "Yes,"      Previously reported         Not previously reported
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.)
In signing the application Face Page, the authorized organizational representative agrees to comply with the policies, assurances and/or certifications
listed in the application instructions when applicable. Descriptions of individual assurances/certifications are provided in Part III and listed in Part I, 4.1
under item 14. If unable to certify compliance, where applicable, provide an explanation and place it after this page.
3. FACILITIES AND ADMINISTRATIVE COSTS (F&A)/ INDIRECT COSTS. See specific instructions.

     DHHS Agreement dated:                                 4/29/2009                                    No Facilities and Administration Costs Requested.

     DHHS Agreement being negotiated with                       DHHS, Division of Cost Allocation                      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.)

a. Initial budget period:          Amount of base      $                       x Rate applied          53         % = F&A costs      $

b. 02 year                         Amount of base      $                       x Rate applied          53         % = F&A costs      $

c. 03 year                         Amount of base      $                       x Rate applied          53         % = F&A costs      $

d. 04 year                         Amount of base      $                       x Rate applied          53         % = F&A costs      $
e. 05 year                         Amount of base      $                       x Rate applied          53         % = F&A costs      $

                                                                                                               TOTAL F&A Costs       $
*Check appropriate box(es):
    Salary and wages base                       Modified total direct cost base                               Other base (Explain)
    Off-site, other special rate, or more than one rate involved (Explain)
Explanation (Attach separate sheet, if necessary.) :




4. DISCLOSURE PERMISSION STATEMENT: If this application does not result in an award, is the Government permitted to disclose the title of
your proposed project, and the name, address, telephone number and e-mail address of the official signing for the applicant organization, to
organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment)?          Yes     No
PHS 398 (Rev. 6/09)                                                         Page                                                         Checklist Form Page

								
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