GIFT Proposal Transmittal

Document Sample
GIFT Proposal Transmittal Powered By Docstoc
					11/2009




                                              UNRESTRICTED RESEARCH GIFT
                                                  TRANSMITTAL FORM
                                      (Internal form is to be used for unrestricted research gifts only)

Submit one original of this form and the sponsor’s gift letter (signed by the appropriate unit official(s)). Do not staple the
transmittal form to the gift letter. The original signatures must be kept on file in OSPRA for audit purposes.

IDENTIFICATIONS                                                                                    Banner Organization Code
UIUC Recipient:
Last                             First and Initial           UIN                Initiating Dept/Division Name E-mail Address                      Phone Number


Donor Name:                                                                         BUDGET INFORMATION:
Donor Mailing Address:                                                              $

COMPLIANCE: (check all that apply). Activities under this gift involve:
   Use of human subjects or HHS               Biotoxins                                                          Consultant payment
   Exemption #
   Use of live vertebrate animals             Corrosive gases                                                    Use of Background Intellectual
                                                                                                                 Property
       Human      and/or Non-Human                         Pyrophoric gases                                      Patent considerations
       Primate materials
       Stem Cells                                          Extremely toxic gases                                 Copyright issues
          Human      Animal                                (Zone A or B)
       Recombinant DNA: Proposal page                      Explosives                                            Use of proprietary or confidential
       #                                                                                                         information
       Transgenic Animals , Seeds                          Discharge of unusual pollutants in                    Space: will require additional
       Plants                                              waste water                                           space be made available to the
       Biological Hazard                                                                                         department or that existing space
                                                                                                                 be renovated.
       Pathogens: Human           , Animal                 Requirement for Environmental                         International program
       Plant                                               Statement                                             Potential Conflict of Interest has
                                                                                                                 been identified and addressed
       Dioxins                                             Other safety or health hazard                         EXPORT CONTROL: ITAR/EAR
                                                                                                                     Use of Foreign Nationals
       Chemical Hazard                                                                                               Covered Technology
The department/unit is responsible for compliance issues such as: use of human subjects or live vertebrate animals, chemical hazards, biological hazards,
patent considerations, consultant payments, potential conflicts of interest, and copyright issues. (Excerpt from Chapter 16.1.5 of the OBFS Policy Manual).
Submit lab animals care protocol form IACUC-1 to the Institutional Animal Care and Use Committee and Research Project Registration form, if needed, to
the Institutional Biosafety Committee electronically. If renovation or additional space is needed, arrangements to meet this need have been made with the
Office of Facility Management and Scheduling and are described on an attachment for internal use.
RESPONSIBILITY OF UIUC RECIPIENT: It is understood that if an award results from this application, the principal investigator will
perform the administrative duties normally associated with the project. The principal investigator assures that he/she makes this
submission with the understanding that any resulting award will contain no provision restricting the University’s right to publish
research results, and that if any question of such restriction arises in subsequent negotiation he/she will assist in arranging the further
review that will be required.
NOTE TO UIUC RECIPIENT(S): By signing this transmittal form, you are certifying that you have submitted a listing of your known
Significant Financial Interests (and those of your spouse and dependent children) that might reasonably appear to be affected by this
activity.
Approved By:
              _________________________________                                ____________________________________
Date          UIUC Recipient (may not be delegated)                Date        Executive Officer(s) of Department(s)

                 _________________________________                                            ____________________________________
                                                                                                                           2
Date             Dean or Director                                            Date             Other Signatures if Required

                 _________________________________                                            ____________________________________
Date             Office of Sponsored Programs and Research                   Date             Research Board Authorization
                 Administration

For information contact:                     Phone:                                     E-mail:

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:12
posted:7/12/2012
language:
pages:1