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									                                                      Boston University Medical Campus/Boston Medical Center

                                                                     Sponsored Program Proposal Summary                                                           Schools of Medicine
           Boston Medical Center                                                                                                                           Dental Medicine, and Public Health
      Boston Public Health Commission                    Boston Medical Center                       Boston University Medical Campus                    Division of Graduate Medical Sciences
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                                               BMC/Boston University ID


Administrative Contact                                                              Contact Phone                      BU or BMC E-mail Address

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
*If you have more than one PI, please supply additional information on 'Multiple PI worksheet'

Application Information
                                                                                                         Indicate submission option:         8/3 days (2-stage)         5 days (regular)
  Funding Agency                                                   Agency Deadline                                                      FOA #
  ARRA (Recovery) Funds?                   Yes           No        CTSI/GCRU Resources Needed?                 Yes     No
  Is this an existing grant?      Yes      No         Agency # (if available)                            BU Source #                                        BMC ACT#

  APPLICATION TYPE:                                               RESEARCH TYPE:                                                   SPONSOR:
          New (N)                                                       Basic Research (B)                                               Federal Grants
          Renewal (Competing Continuation) (R)                          Clinical-Federal ( C)                                            Subcontract (indicate source below)
          Non-Competing Continuation (NC)                               Clinical - Non-Federal (CNF)                                     Government Contracts (city, state or federal)
          Administrative Supplement (S)                                 Training (T)                                                     Industry
          Transfer (T) (indicate source below)                          Service/Education Program (S/E)                                  Foundation: Public or Private
          Resubmission                                                  Other Research (BH)                                              Foreign
          Revision (formerly Competing Supplement)                                                                                        Other
                    Will this application be submitted electronically?   Yes           No

  If this is a Transfer, from where?                                                       If this is a Subcontract, from where?

  Is this a MODULAR GRANT?                      Yes           No                                                                   Conflict of interest form attached?        Yes       No

Project Information

  Project Title
                                                                                   Proposed Year                                                         Entire Project
  EFFECTIVE DATES OF PROJECT (MM/DD/YY)                       FROM:                        TO:                                     FROM:                          TO:

                                                           Project Approval**          Protocol/Approval No.
  USE OF:                               YES**     NO      (Date or "Pending")            For Each Project                   Are there any Subcontracts?                       Yes       No
               HUMAN SUBJECTS1                                                                                              If YES, how many?                             0
               ANIMALS                                                                                                      Are there any Consultants?                        Yes       No
               RADIOISOTOPE                                                                                                 If YES, how many?                         0
                                                                                                                            .
               RECOMBINANT DNA                                                                                              Please List Institution/Consultant Name (or attach list):
               IBC APPROVAL
             SELECT AGENTS?                         If Yes, What NBL level?
  1
     Applications with multiple projects or subcontractors must also obtain IRB approval for each
  subcontract or project that has human subjects
  ** For Continuations attach copies of approval letters and/or certifications

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/policies/rreach.html); (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 (see page 2 for more information).


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                                                                Date


Chairman Approval (Signature)                                             Date                           Grants Administration                                                      Date



                                                                                                                                                                        Version 7/14/09
                                                   Boston University Medical Campus/Boston Medical Center

                                                                 Sponsored Program Proposal Summary                                                                     Schools of Medicine,
           Boston Medical Center                                                                                                                                Dental Medicine, and Public Health
      Boston Public Health Commission                                                           Page 2                                                         Divisoin of Graduate Medical Sciences

Location of Project & Special Requirements
Use drop-down menus in shaded cells below to select BUMC/BMC site(s) where research will be performed. (Note: regarding industry-sponsored clinical research, all applications are submitted
by BUMC ORA 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.
Does your project require renovations to existing research space?                Yes       No    If Yes, please attach commitment letter from Facilities Department

Does your project require the services of the BU/BMC Information Technology Department?                   Yes       No         If Yes, please attach IT commitment letter

Budget for Proposed Year
Direct Costs                                                                           If BUMC: Indirect Costs
     1. Equipment                                                                          10a. BUMC: Modified Total Direct Costs (5+6+8)                                                       $0.00

     2. Space Rental or Renovations                                                        11a. BUMC: F&A Rate (See Table & Notes Below)                                                        0.625
     3. Patient Care Costs                                                                 12a. BUMC: Total Indirect Costs (10a*11a)                                                            $0.00

     4. Tuition and Fees                                                                13a Proposed Year Total Costs (9+12a)                                                                   $0.00

     5. Animal Costs

     6. All Other Direct Costs                                                         If BMC: Indirect Costs
     7. Subcontracts                              $                          -             10b. BMC: Modified Total Direct Costs (5+6)                                                          $0.00

       (automatically populated from page 3)                                               11b. BMC: F&A Rate (See Table & Notes Below)                                                          0.25
     8. Subk amount subject to F&A calc**                                   $0.00          12b. BMC: Total Indirect Costs (10b*11b)                                                             $0.00

    9. Total Direct Costs (sum 1 through 7)                                 $0.00       13b Proposed Year Total Costs (9+12b)                                                                   $0.00


**BUMC ONLY, appropriate column of line 18, page 3                                      Facilities and Administrative Rate (F&A)               Matching Funds/Cost-Sharing?**
                                                                                                    On Site              Off Site                         Yes
                                                                                                    69%                  23.70%
                            Estimate for Entire Project                                    BMC                                                            No

       Total Direct Costs                                                                           On Campus            Off Campus             If Yes, List the Source Activity # (s)
                                                                                                    62.50%               26%
       Total Indirect Costs                                                                BU
       Total Costs                                                                         Sponsor's Indirect Rate Cap                   %

    ** Cost Sharing only: If you responded "Yes" to the Cost Sharing section, the PI must INITIAL the following statement:
       "I certify that I have voluntarily committed institutional funds towards the proposed project. If awarded, these funds will be expensed to a non-federal institutional account, and
       managed by my office"            Principal Investigator Initial: _________________________

Facilities & Administrative Costs/Indirect Costs
   Facilities and Administrative (F&A) or indirect cost calculation equals Modified Total Direct Cost (MTDC) times the F&A rate. MTDC is Total Direct Cost LESS capital
expenditures (individual items of equipment > $5,000; renovations or alterations; building costs; rental/maintenance of off-site space); the portion of each subcontract
in excess of $25,000 (BU only); student tuition remission and support costs (e.g., stipends, student aid, dependency allowances, scholarships, fellowships); and/
or hospitalization and other patient care costs. In line 11a, enter F&A rate as decimal, not whole number, e.g., 0.625.
  To select the F&A rate for Boston University, determine where the predominance of effort will be performed. If 50% or more of effort will be within BU owned or leased
space, use the On Campus F&A rate. If 50% or more effort will be at locations outside of Boston University Medical Campus space, use the Off Campus F&A rate.
   To select the F&A rate for Boston Medical Center, determine where the predominance of effort will be performed. If 50% or more of effort will be within BMC owned or
leased space, use the On Site F&A rate. If 50% or more effort will be at locations outside of Boston Medical Center space, use the Off Site F&A rate.
  If the Sponsor has an Indirect Rate Cap indicate the rate in the F&A rate box and use that rate in the calculation.

Approval for F&A Exceptions
       If this project involves F&A cost negotiations, additional space and/or space renovations, or cost sharing arrangements, then you must contact either the
       Director of the ORA at Boston University or one of the Associate Directors at Boston Medical Center.

Additional Assurances - Publication & Clinical Trial Registration
    About ClinicalTrials.gov
      ClinicalTrials.gov offers up-to-date information for locating clinical trials.
      The FDA Amendments Act of 2007 contains new trial registration requirements at ClinicalTrials.gov. Consequences of not registering include monetary and civil penalties. PIs are
    responsible for determining whether or not they are obligated to register in accordance with the law.
      Even if you and/or your trial are not covered by this law, it makes sense to register your trial for a variety of other reasons, the most important of which may be to allow its
    publication in the peer-reviewed medical literature. The International Committee of Medical Journal Editors, including JAMA, NEJM, Annals of Internal Medicine, Lancet, continues to
    require, as a condition of publication, registration in a public trials registry.
       For more information visit the Office of Clinical Research website: http://www.bumc.bu.edu/ocr/
    NIH Public Access Policy
    The NIH Public Access Policy ensures that the public has access to the published results of NIH funded research.
      All investigators funded by NIH must submit to the National Library of Medicine’s PubMed Central (http:www.pubmedcentral.nih.gov) an electronic version of their final, peer-
    reviewed manuscripts upon acceptance for publication, to be made publicly available no later than 12 months after the official date of publication. See NIH Guide Notice NOT-OD-08-
    033 for further information.

Additional Comments




(e.g., Agency restrictions, cost sharing information, space issues, etc.)
                                                                                                                                                                                          Version 7/14/09
BU MEDICAL CAMPUS CALCULATION WORKSHEET FOR SUBCONTRACTS

For subcontract that begins in year 1 of BUMC award year, enter numbers as instructed.
                  $$               $$           $$              $$              $$                 $$               $$            $$           $$       $$         $$

                                                                                                                  Year 2                              Year 3
           Year 1 direct      Year 1 F&A                   Year 1 amount     Year 1 F&A to                      amount for    Year 2 F&A Enter year amount for Year 3 F&A
            cost at subk      cost, subk     Year 1 direct for calculating   BU from subk     Enter year 2      calculating   to BU from  3 direct  calculating to BU from
Subcontract institution        institution    cost to BU        F&A*               **      direct cost to BU       F&A*         subk **  cost to BU    F&A*       subk **

          1      0.00            0.00            0.00           0.00             0.00             0.00             0.00          0.00         0.00     0.00       0.00

          2      0.00            0.00            0.00           0.00             0.00             0.00             0.00          0.00         0.00     0.00       0.00

          3      0.00            0.00            0.00           0.00             0.00             0.00             0.00          0.00         0.00     0.00       0.00

          4      0.00            0.00            0.00           0.00             0.00             0.00             0.00          0.00         0.00     0.00       0.00

          5      0.00            0.00            0.00           0.00             0.00             0.00             0.00          0.00         0.00     0.00       0.00

                                Total,
                             subcontracts        0.00           0.00             0.00             0.00             0.00          0.00         0.00     0.00       0.00



NOTE: BU MEDICAL CAMPUS applies F&A charges on the first $25000 of each and every subcontract.

* If the subcontract amount in year 1 is less than $25000, enter the subcontract amount and carry over balance into years 2 and following. Enter the
subcontract amount in each year until you reach the $25000 limit.

** Spreadsheet uses BU MEDICAL CAMPUS on-campus F&A rate as default. Change the default rate to the appropriate rate as necessary:
On campus research, 62.5%; instruction and training, 56%; other, 49%; industry and clinical, 30% of total direct cost
Off campus, all programs, 26%

NOTE: When calculating the total project F&A charges, remember to match the subcontract year with actual BU MEDICAL CAMPUS award year.
   $$          $$         $$          $$          $$         $$

             Year 4                            Year 5
Enter year amount for Year 4 F&A Enter year amount for Year 5 F&A Total per
 4 direct  calculating to BU from  5 direct  calculating to BU from   Subk
cost to BU    F&A*       subk **  cost to BU    F&A*       subk **  Institution

  0.00        0.00        0.00       0.00        0.00       0.00        0.00

  0.00        0.00        0.00       0.00        0.00       0.00        0.00

  0.00        0.00        0.00       0.00        0.00       0.00        0.00

  0.00        0.00        0.00       0.00        0.00       0.00        0.00

  0.00        0.00        0.00       0.00        0.00       0.00        0.00


  0.00        0.00        0.00       0.00        0.00       0.00        0.00
                                                         double-check   0.00
                                                                                   Multiple PI Table
                                                  Boston University Medical Campus/Boston Medical Center
                                                                 Sponsored Program Proposal Summary                                                      Schools of Medicine
         Boston Medical Center                                                                                                                  Dental Medicine, and Public Health
    Boston Public Health Commission                  Boston Medical Center                     Boston University Medical Campus                Division of Graduate Medical Sciences
#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

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/policies/rreach.html); (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 (see page 2 for
more information).


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


Chairman Approval (Signature)                                         Date

#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

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/policies/rreach.html); (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 (see page 2 for
more information).

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


Chairman Approval (Signature)                                         Date




                                                                                                                                                             Version 7/14/09
BU MEDICAL CAMPUS 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

BU MEDICAL CAMPUS 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.
560 Harrison Ave (Medical Information Systems Unit), 4th
floor room 405
Crosstown Center, 801 Massachusetts Ave, floor 2
Biosquare III, 670 Albany St, floor 2,3
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
Maternity Building, 91 East Concord 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
Yawkey Building (fka Ambulatory Care Center), 850
Harrison Ave

								
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