EVALUATION PLAN: TELEPHONE SURVEY SAMPLE by 1N8rNn9Z

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									                                            Subcontract/Amendment Request Form

To:
From:
Re:       Subcontract/Amendment Request
Date: Tuesday, November 06, 2012

Note: Please complete all items in this memo and return with attachments to my attention for processing.
Appendices must be typed attachments. Once the subcontract/amendment is complete it will be returned for
your review before forwarding for execution.


1.     Project ID

2.     Indicate type of document:         New subcontract          Amendment to existing subcontract
       If this is a modification, please explain what in the original subcontract needs to be modified.
3.



       Name of the Subcontractor
4.
       (University/Organization/etc.)
5.     Period of performance for the                                From:                   To:
       subcontract/amendment

6.    Contact information for                           Name:                     Title:
      Subcontractor PI
                                                        Address:


                                                        Telephone:               Fax:
                                                        Email:
7.     Contact information for                           Name:                     Title:
       Subcontractor Contract
                                                         Address:
       Administrator

                                                         Telephone:               Fax:
                                                         Email:

8.     To whom at Subcontractor should                   Name:                    Title:
       FIU mail the completed
                                                         Address:
       subcontract/amendment?

                                                         Telephone:                Fax:
                                                         Email:

9.     Statement of work for the subcontractor (please attach typed statement of work as Appendix A)
C:\Docstoc\Working\pdf\98ea492c-0888-43ca-982a-afcf8bbb4cda.doc                                        11/6/2012
10. Budget or deliverable schedule for the subcontractor's work (please attach budget as Appendix B)
11. Termination Notice 30 or 60 days?
12. Subcontract above 75K requires a Bid Exemption Certification (online form: http://research.fiu.edu/)
13. Conflict of Interest: Is there any existing or potential conflict of interest relating to this subcontract
    and the research project?
           Yes      No See the Conflicts of Interest in Research policy, #2370.005, at
       http://policies.fiu.edu/files/572.pdf for more information. Note that disclosures are required from all
       FIU personnel, whether they are full or part-time employees or volunteers, if such persons have a
       conflict of interest as relates to the research project. This includes, but is not limited to, volunteer
       faculty, adjuncts and students.
       If you answered YES above, the applicable FIU individual must complete the Outside
       Activity/Conflict of Interest Report at http://hr.fiu.edu/index.php?name=conflict_of_interest. The
       disclosure will be reviewed to determine if the conflict can be managed, reduced or eliminated so that
       the subcontract may proceed.
14. IBC, IRB or IACUC Approvals: Will there be any Recombinant DNA molecules, Human Subjects
    (including surveys) and/or Animal Use studies done at the Subcontractor’s site? Yes No
15. Previously Executed Agreements: Is this subcontract related to a previously executed Non-
    Disclosure or Propriety Information Agreement.  Yes       No


PI Signature: ___________________________________                     Date: __________________

Name (typed):
Phone:
Fax:




                                                         FOR DoR USE ONLY
       Restricted Parties Search (RPS) completed on:              ___________/_______________/____________
       RPS results attached to this memo.

DoR Representative Signature: ______________________________ Date: _______________________




C:\Docstoc\Working\pdf\98ea492c-0888-43ca-982a-afcf8bbb4cda.doc                                       11/6/2012

								
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