BARNES-JEWISH HOSPITAL FOUNDATION - DOC

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					        Designated Funding Request
      Grant Application & Instructions
                 Barnes-Jewish Hospital Affiliate Applicants
                FBJH Form – DFR 02 (Effective January 1, 2010)




The mission of The Foundation for Barnes-Jewish Hospital is to provide financial support to help the
Hospital fulfill its purpose. Funds are used to support medical research, patient care, education, and
community service projects that otherwise would not be available to the Hospital.



                                                    1      FBJH Form – DFR 02 (Effective January 1, 2010)
              THE FOUNDATION FOR BARNES-JEWISH HOSPITAL
                             INSTRUCTIONS
                      (Request for Designated Funding)

FBJH Form - DFR 02 contains information for preparing a request for funding to The Foundation for
Barnes-Jewish Hospital for designated funds.

Designated Funding
       - Non-Research Grants for investigators whose affiliated hospital currently has funds
           assigned and/or designated for their use.

                 Electronic forms for this funding request and supporting materials are available at
             (http://www.barnesjewish.org/giving/about-us/grants-administration)


Please read and follow the instructions and guidelines carefully to avoid delays, misunderstandings, and
the possible return of a request for clarification or changes.

The deadline for filing a request for funding is 5:00 p.m on the submission date. The Foundation reserves
the right to deny late requests. Please direct questions and submissions to:

 The Foundation for Barnes-Jewish Hospital
 Pamela Jayne
 Grants Coordinator
 1001 Highlands Plaza Drive West, Suite 140
 Saint Louis, MO 63110
 Phone: 314-286-0349
 Email: pjj6479@bjc.org



                           GRANT FUNDING REQUEST SCHEDULE

 SUBMISSION CYCLE                              GRANT                                      GRANT
    DEADLINE                                 START DATE                                  END DATE
            May 1st                                July 1st                                 June 30th

         November 1st                           January 1st                              December 31st

Project Narrative
Briefly describe your plans for using this funding in one to two paragraphs (see page 8). Include a brief
description of your objectives, timetable, expected outcomes, the role of any consortium/contractual
institution (if applicable), and an explanation of how your use of this award will directly and/or indirectly
impact patients or the practice of medical care, now or in the future. Please keep in mind that using
layman’s terms will assist us in stewarding our fund donors.

Budget
The attached budget form(s) must accompany the application. If applicable, a budget for the consortium
institution must accompany the application. Applicable letters from contracted institutions and/or parties
must also accompany the application.


                                                        2      FBJH Form – DFR 02 (Effective January 1, 2010)
                          TERMS AND CONDITIONS OF GRANT

EXPENDITURE GUIDELINES
A.      Equipment
        A detailed description of the equipment must be provided with an explanation of how it directly relates to
        the project. Equipment is defined by the grantee’s institutional capital policy.

B.      Travel
        Travel must adhere to the grantee’s established travel policy. The relationship of the traveler to the grant
        must be identified.

C.      Consortium
        The participating consortium organization must submit a separate face page and detailed budget for both
        the initial budget period (Form Page 6) and the entire proposed project period (Form Page 7).

        Consortium arrangements may involve personnel costs, supplies, and other allowable costs, including
        indirect costs.

D.      Contractual Costs
        Contractual arrangements (e.g. laboratory testing, clinical services or data processing) must be supported
        by a letter from the contracted institution which defines the terms and documents their agreement to
        participate.

        These costs should be reflected in the other expense budget category.

E.      Pre-Award Costs
        An applicant may, at their own risk and without prior approval from the Foundation, incur obligations and
        expenditures to cover costs up to 90 days before the beginning date of the initial budget
        period if such costs:
                       are necessary to conduct the project, and
                       would be allowable under the grant, if awarded.

        Pre-Award costs must be explained in the project narrative and detailed on the budget page.

F.      Unallowable Expenditures
        The Foundation for Barnes-Jewish Hospital will not fund the following:
                     Administrative or institutional charges for services normally considered overhead, (e.g.,
                         space rental, utilities, etc.)
                     Tuition (excluding scholarships)
                     Dependent tuition fringe benefit
                     Dues and membership fees (excluding professional organizations or societies)
                     Entertainment/social expenses or other non-business related activities (e.g., office parties,
                         amusements, diversion, etc.)
                         Prior period costs (excluding pre-award costs)
                     Any expense contrary to applicant’s institutional reimbursement policies

        The Foundation reserves the right to question and/or disallow a cost that it deems inappropriate.

REPORTING GUIDELINES
     A. Donor Report
                A Donor Report will be requested at the end of the budget period to permit the Foundation to
                 appropriately steward its donors to funds. Guidelines and forms for submitting an acceptable
                 donor report will be provided with award documents. Future disbursements may be affected if
                 Principal Investigator is delinquent in submitting their Donor Report by the due date.

                                                          3       FBJH Form – DFR 02 (Effective January 1, 2010)
  B. Interim Donor Report (multi-year awards only)
            An Interim Donor Report will be requested at the end of the budget period. Guidelines and forms
             for submitting an acceptable donor report will be provided with award documents. Future
             disbursements may be affected if Principal Investigator is delinquent in submitting their Interim
             Donor Report by the due date.

ADMINISTRATIVE GUIDELINES
     A. Carryover (multi-year awards only)
            Carryover of an unobligated balance into the next budget period will be automatic for projects
             with an acceptable Interim Donor Report.

     B. No Cost Extension
            Requests for extensions must be submitted two weeks prior to the date of expiration. An
             extension may be granted for one year to complete the work. Requests must be approved by the
             Grantee’s Institutional official and The Foundation for Barnes-Jewish Hospital. Justification must
             be provided with the request. Requests should be submitted to The Foundation for Barnes-Jewish
             Hospital, Grants Coordinator via email at pjj6479@bjc.org.

     C. Change in Grantee or Grantee Institution
            Changes in the Grantee must be approved in advance by Grantee’s institutional official and The
             Foundation for Barnes-Jewish Hospital. No changes in the Grantee Institution will be allowed.

     D. Change in Scope
            Any change in the direction, program/activity, or other areas that constitute a significant change
             from the aims, objectives, or purposes of the approved project must be approved in advance by the
             Grantee’s institutional official and The Foundation for Barnes-Jewish Hospital.

     E. Change in Effort
            Grantees are required to devote adequate effort to complete the project. Any change to the
             original commitment of effort must be approved by the Grantee’s institutional official and The
             Foundation for Barnes-Jewish Hospital. Justification should be provided with the request.

     F. Budget Modifications
            Rebudgeting is allowed if it meets the purpose of completing the project. Funds may not be
             rebudgeted for items deleted from the original budget. Any rebudgeting that changes a budget
             category by 25% or greater must be addressed in the donor report.

             Significant rebudgeting requires approval in advance by the Grantee’s institutional official and
             The Foundation for Barnes-Jewish Hospital. This occurs when expenditures in a single direct cost
             budget category increase or decrease from the categorical commitment level established for the
             budget period by more than 25% percent of the total costs awarded. For example, if the award
             budget for total costs is $100,000, any rebudgeting that would result in an increase or decrease of
             more than $25,000 in a budget category would be considered “significant rebudgeting”.

     G. Discoveries/Inventions
            Discoveries and/or inventions resulting from The Foundation for Barnes-Jewish Hospital funding
             will be subject to Barnes-Jewish Hospital’s policy on Intellectual Property. All grant recipients
             are required to report discoveries/inventions in the Donor Report.

     H. Acknowledgement of Funding
            The Foundation for Barnes-Jewish Hospital must be acknowledged in any publication or
             presentation resulting from a Foundation grant. All grant recipients are required to report any
             publications in the Donor Report. Copies of all abstracts and reprints acknowledging The
             Foundation for Barnes-Jewish Hospital must be submitted to the Grants Coordinator at The
             Foundation for Barnes-Jewish Hospital.




                                                     4       FBJH Form – DFR 02 (Effective January 1, 2010)
                                       The Foundation for Barnes-Jewish Hospital
                                          Affiliate Designated Grant Application

1. Title of Project

                                                             st                                                                       st
                              2a.          Cycle One - May 1 Submission                         2b.      Cycle Two - November 1 Submission
2. Budget Period
                                            (July 1, 2011 – June 30, 2012)                               (January 1, 2012 – December 31, 2012)

3. Type of Grant              3a.          New               3b.     Supplement           If yes, include your current grant number _____________

                             Check all that apply:
4. Project Purpose
                                      Education        Equipment       Patient Care           Community/Outreach             Other _____________

                            5a. Pre-Award (up to 90 days):   Yes     No
                                   Cycle One: April 1, 2011 – June 30, 2011                               Pre-Award Request:                $
                                   Cycle Two: October 1, 2011 – December 31, 2011
                             Amount Requested: $                                                          Budget Period Request: $
5. Funding Request
                            5b. Budget Period (see budget pages for multi-year eligibility):
                                                                                                          ---------------------------------------------------------
                                    Single Year       Multi-Year
                                                                                                          Total Grant Request:             $
                             Amount Requested: $
                            Fund Number                                        Fund Number                               Fund Number
6. Fund Information
                            Amount $                                           Amount $                                  Amount $

7. Applicant Information
   Name: (Last, First, MI)                                               Degree(s) (e.g., MD, PhD, RN)          Phone Number           Fax Number


   Title                                                                 Applicant’s Mailing Address:

   Applicant Organization


   Department                               Division
                                                                         Applicant’s E-mail Address:

Administrative Contact:

Name:                    Phone Number:                                 Email Address:
For questions regarding my application, contact:                         For questions regarding my Project Narrative, contact:
       Applicant      Administrator                                            Applicant      Administrator

For questions regarding my budget, contact:                              For questions regarding my Donor Report, contact:
       Applicant      Administrator                                            Applicant      Administrator
8. Project Narrative                    The project narrative should include a brief description of the objectives, timelines, expected
(see page 8 to complete your
narrative in one to two paragraphs)
                                        outcomes, the role of any consortium/contractual institution (if applicable), and an explanation
                                        of how the project will directly and/or indirectly impact patients.
9. Acceptance of Terms and Conditions
I, the undersigned, certify that the statements herein are true and              Official Signing for Applicant Organization (Please Type or Print Name)
completed to the best of my knowledge. I agree to comply with all                Name:
policies, terms, and conditions of The Foundation for Barnes-Jewish
Hospital.                                                                        Title:

Principal Investigator/Program Director:                                         Address:
(Please Type or Print Name)
                                                                                 Tel:                         Email:




Signature:                                               Date:                   Signature:                                                 Date:


                                                                             5            FBJH Form – DFR 02 (Effective January 1, 2010)
            Applicant’s Name (Last, First, Middle):

                                                                                              FROM                    THROUGH
         DETAILED BUDGET FOR INITIAL BUDGET PERIOD
       (Pre-award Costs must be itemized in the categories below)
1. PERSONNEL                                                                     %              DOLLAR AMOUNT REQUESTED (omit cents)



                                                                  Please      EFFORT
                                                      ROLE ON    Identify       ON           SALARY          FRINGE
                       NAME                           PROJECT   Institution    PROJ.       REQUESTED        BENEFITS           TOTAL




                                      SUBTOTALS
2. CAPITAL EQUIPMENT (Itemize)



3. TRAVEL


4. PUBLICATIONS


5. CONSUMABLE SUPPLIES (Itemize by category)




6. COST SHARING (Itemize by category)




7. PATIENT CARE



8. STIPENDS (Itemize by category)


9. CONSULTANT(S)



10. CONSORTIUM


11. PC HARDWARE/SOFTWARE or SERVICE AGREEMENTS (Specify and Itemize)




12. OTHER EXPENSES (Itemize by category)



13. TOTAL COSTS FOR INITIAL BUDGET PERIOD
     (including any requested Pre-award costs)                                                                            $


                                                                     6        FBJH Form – DFR 02 (Effective January 1, 2010)
MULTI-YEAR: If your project/program is a two year specific project/program and NOT an annual funding need, you
may request a second year of funding below.
                                                                                             FROM                    THROUGH
     DETAILED BUDGET FOR SECOND YEAR BUDGET PERIOD
                     Applicant’s Name (Last, First, Middle):
1. PERSONNEL                                                                    %              DOLLAR AMOUNT REQUESTED (omit cents)

                                                                 Please      EFFORT
                                                ROLE ON         Identify       ON           SALARY          FRINGE
                     NAME                       PROJECT        Institution    PROJ.       REQUESTED        BENEFITS           TOTAL




                                    SUBTOTALS
2. CAPITAL EQUIPMENT (Itemize)




3. TRAVEL


4. PUBLICATIONS


5. CONSUMABLE SUPPLIES (Itemize by category)



6. COST SHARING (Itemize by category)




7. PATIENT CARE



8. STIPENDS (Itemize by category)


9. CONSULTANT(S)



10. CONSORTIUM


11. PC HARDWARE/SOFTWARE or SERVICE AGREEMENTS (Specify and Itemize)



12. OTHER EXPENSES (Itemize by category)




13. TOTAL COSTS FOR SECOND YEAR BUDGET PERIOD
                                                                                                                         $


                                                                    7        FBJH Form – DFR 02 (Effective January 1, 2010)
          Section 8 continued…


Applicant’s Name:                                                           Budget Period:                    through

Project Narrative (please describe your intended usage of this grant, in layman’s terms, in one to two paragraphs)
-----The project narrative should include a brief description of the objectives, timelines, expected outcomes, the role of any
consortium/contractual institution (if applicable), and an explanation of how the project will directly and/or indirectly impact patients.
-----If you are requesting Pre-award costs, please include a separate paragraph explaining the objectives, timelines, and budget.




                                                                        8       FBJH Form – DFR 02 (Effective January 1, 2010)

				
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