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BMC grants Proposalsheetfinal2010 by yq3ifIr

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									                                                                          Boston University/Boston Medical Center
                                                                          Sponsored Program Proposal Summary

             BU-MED                                                                                     BU-CRC                                                          Boston Medical Center
 Title of Project:
Principal Investigator Information

 Principal Investigator (Last Name)                       (First Name)                                         (MI)        School (BU only)                             Dept/Division

 Section (If applicable)                    Unit/Dept (BU only)                                               Bldg & Room #                           Co-Investigator


        PI Phone                                                       FAX Number                                                     BU or BMC E-mail Address


 Administrative Contact                                                               Contact Phone                                   BU or BMC E-mail Address

 Is this a Multi-PI Application?            Yes           No       If Yes, all PD/PIs must sign below
                                                                                                                                                   BMC/Boston University ID
Budget Information
                                                                                         Proposed Year                                                               Entire Project
     Effective Dates of Project (MM/DD/YY)                     FROM:                                    TO:                                   FROM:                          TO:
             Funds Requested                                           Budget Direct Costs                                                    Project Direct Costs
                                                                       Budget Indirect Costs                                                  Project Indirect Costs
                        69
        F & A Rate                    %                                Budget Total Costs                      $0.00                          Project Total Costs                   $0.00
Project Information & Compliance
                                                         Project Approval**     Protocol/Approval #
 Special Reviews                                        (Date or "Pending")      For Each Project       Are there any Subcontracts?                Yes        No        If Yes, How Many?
 IRB                            Yes           No                                                        Sponsor Salary Cap Apply?                  Yes        No
 IACUC                          Yes           No                                                        Major Projects (see A21)?                  Yes        No        (BU only)
 IBC Biohazards                 Yes           No                                                        Consultants?                               Yes        No        If Yes, How Many?
 IBC rDNA                       Yes           No                                                        ARRA Funding?                              Yes        No
 IBC Select Agents              Yes           No                                                        Modular Grant?                             Yes        No
 Radioisotopes                  Yes           No                                                        Cost Sharing/Matching?                     Yes        No        If Yes, please list Account(s)
 Scuba/Snokeling             Yes          No                                                                   Direct Cost Share                           ($)
 ** Applications with multiple projects or subcontractors must also obtain IRB approval for                    Indirect Cost Share                         ($)
 each subcontract or project that has human subjects
Application Information

 Funding Agency/Prime Sponsor                                  Agency Deadline                                         FOA/Solicitation Number
                           <Select>                                                                                    <Select>
 Application Type                                                                              Prime Sponsor Type
                           <Select>                                                                                    <Select>
 Activity Type                                                                                 Submission Method

 Is this a Transfer? If Yes, From Where:                                                                       CTSI/GCRU Resources Needed? (BU-MED/BMC Only)                              Yes    No
 Is this a Subcontract?               Yes          No     If Yes, From Where?

 If this is an existing grant, please provide
                                                            Agency # (if available)                     BU Source Number                      OR      BMC Account Number
 BMC ONLY: If non-competing or resubmission, any changes to previously submitted FCOI forms? Or any new investigative staff?                               Yes          No
 If Yes, to either question, must submit new COI form

Assurances
PI/Sponsor Assurance: I certify that: (1) in conducting the proposed program, I am familiar with and will adhere to applicable Boston University/Boston Medical Center policies
including, but not limited to, human and animal research, conflict of interest, misconduct in research, and patents and technology transfer (http://www.bu.edu/research/compliance/);
(2) the information submitted within the application is true, complete, and accurate to the best of the my (the PI's) knowledge; (3) any false, fictitious, or fraudulent statements or claims
may subject me (as the PI) to criminal, civil, or administrative penalties; (4) I (as the PI) 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 the application; and (5) I will abide, as applicable, by the Federal clinical trials (ClinicalTrials.gov: http://clinicaltrials.gov/) and NIH
Public Access (http://publicaccess.nih.gov) regulations.


 PD/PI Signature                                                       Date                                   PD/PI Signature                                                      Date


 PD/PI Signature                                                       Date                                   PD/PI Signature                                                      Date
Departmental Assurance: Faculty status, research/training program, space/facilities, personnel/efforts/salaries/wages, and budgets have been reviewed and approved.


Chief of Service (Signature)                                           Date                             Reviewed by BU OSP/BMC Grants Admin Staff                            Date


Chairman/Dean Approval (Signature)                                     Date                             Authorized Organization Representative                               Date




                                                                                                                                                                                                         Version 7/14/09
                                                                       Boston University/Boston Medical Center
                                                                       Sponsored Program Proposal Summary
                                                                                                    Page 2

            BU-MED                                                                                  BU-CRC                                                Boston Medical Center
Location of Project & Special Requirements
 Does your project require renovations to existing research space?                                                        Yes            No

 Does your project require new space                                                                                      Yes            No

 Do you plan to purchase a major piece of equipment under this award?                                                     Yes            No
 Does your project require the services of the BU-MED/BMC Information Technology Department?                              Yes            No

 BU-CRC Only:

 Location of Work on Project                                                  On-Campus Effort                            %       Off-campus Effort                                  %

  BU-MED/BMC Only: Use drop-down menus in shaded cells below to select BU-MED/BMC site(s) where research will be performed. (Note: regarding industry-sponsored clinical
 research, all applications are submitted by OSP-MED including those in BMC space. If unsure whether research is on a BMC site, consult drop-down list by clicking in third shaded
 line below)
 Select Building Location (cllick in the cells below)                                               Enter Building Letter         Enter Room Number     Enter Space Allocation %
 Select BUMC site from drop-down list.
 Select BUMC site from drop-down list.

 Select BMC site from drop-down menu.

 Select BMC site from drop-down menu.


Mentor (if applicable)


 Mentor (Last Name)                                                           (First Name)               (MI)          School (BU only)                   Dept/Division


 Mentor Phone                                                            FAX Number                    BU or BMC E-mail Address                           BMC/Boston University ID

International Research
            Does this project have any of the following international components (check all that apply):
                    A collaborator outside of US
                    Travel outside of US by any BU participant (e.g. faculty, staff, students) in this project (paid or unpaid)
                    Travel to the US by any collaborator involved with this study (paid or unpaid)
                    Transport of any samples (e.g. tissue, blood, chemical) to or from US
            Please provide contact information for the individual who is familiar with this project and who should be contacted by the Research Compliance Coordinator for further
            information.

            Name:                                                                  Phone:                                            e-mail:

Additional Comments




 (e.g., Agency restrictions, cost sharing information, space issues, etc.)




                                                                                                                                                                          Version 7/14/09
                                                                         Multiple PI Table
                                                            Boston University/Boston Medical Center
                                                            Sponsored Program Proposal Summary

             BU-MED                                                          BU-CRC                       Boston Medical Center
#2 Principal Investigator Information

Principal Investigator (Last Name)          (First Name)              (MI)     School (BU only)           Dept/Division


Section (If applicable)                     Unit/Dept (BU only)                Bldg & Room #


PI Phone                             FAX Number                   BU or BMC E-mail Address            Boston University ID

#3 Principal Investigator Information


Principal Investigator (Last Name)          (First Name)              (MI)     School (BU only)           Dept/Division


Section (If applicable)                     Unit/Dept (BU only)                Bldg & Room #


PI Phone                             FAX Number                   E-mail Address                      Boston University ID

#4 Principal Investigator Information

Principal Investigator (Last Name)          (First Name)              (MI)     School (BU only)           Dept/Division


Section (If applicable)                     Unit/Dept (BU only)                Bldg & Room #


PI Phone                             FAX Number                   BU or BMC E-mail Address            Boston University ID




                                                                                                                                  Version 7/14/09
BUMC ON-CAMPUS
560 Harrison Ave, floor 3
580 Harrison Ave, floors 2, 3, 4
609 Albany St
801 Albany St
Crosstown Center, 801 Massachusetts Ave, floors 3, 4
Biosquare III, 670 Albany St, floors 1, 4, 5, 8
Building A (School of Medicine), 80 East Concord St
CABR (Center for Advanced Biomedical Resarch), 700
Albany St
Charles River Campus, various addresses
Conte Building, 71 East Concord St
EBRC (Evans Biomedical Research Center), 650 Albany St,
floors B, 1, 2, 3, part of 7
Evans Building, 75 East Newton St
Henry M. Goldman School of Dental Medicine, 100 East
Newton St
Housman Building, 80 East Concord St
Instructional Building (School of Medicine), 80 East
Concord St
Naval Blood Research Laboratory, 615 Albany St
Robinson Building B, 80 East Concord St
Solomon Carter Fuller Mental Health Center, 85 East
Newton St, part of floors 8, 9, 10
Talbot Building, 715 Albany St

BUMC OFF-CAMPUS
VA Boston Health Care System (Boston VA), 150 South
Huntington Ave, Boston, Building 1A
VA Boston Health Care System (Boston VA), 150 South
Huntington Ave, Boston
Edith N. Rogers Memorial Veterans Hospital (Bedford VA),
200 Springs Rd, Bedford
73 Mt. Wayte Ave, Framingham
Slone Epidemiology Center, 1010 Commonwealth Ave,
Boston
BMC sites
Select BMC site from drop-down menu.
Crosstown Center, 801 Massachusetts Ave, floor 2
Biosquare III, 670 Albany St, floor 2, 3, & 6
Doctor's Office Building, 720 Harrison Ave
Dowling Building, 754 Massachusetts Ave
EBRC (Evans Biomedical Research Center), 650 Albany St,
floors 4-6, 8, part of 7
FGH Building, 820 Harrison Ave
Finland Laboratory, 754 Albany St
Health Services Building, 70 East Newton St
J. Joseph Moakley Building, 830 Harrison Ave
Mallory Building, 774 Albany St
Menino Building (Harrison Pavilion), 840 Harrison Ave
Newton Pavilion, 88 East Newton St
Preston Building, 732 Harrison Ave
Robinson Complex (fka C & D, Collamore, Old Evans), 88
East Newton St
Surgical Building, 85 East Concord St
Vose, Floors 2 - 5
Yawkey Building (fka Ambulatory Care Center), 850
Harrison Ave

								
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