FACE AA

Document Sample
FACE AA Powered By Docstoc
					Form Approved Through 09/30/2007                                                                                                                           OMB No. 0925-0001
                      Department of Health and Human Services                                       LEAVE BLANK—FOR PHS USE ONLY.
                                      Public Health Services                                        Type                Activity                Number
                                                                                                    Review Group                                Formerly
                                 Grant Application
       Do not exceed 56-character length restrictions, including spaces.                            Council/Board (Month, Year)                 Date Received
1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation.)


2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION                                                                             No       Yes
 (If "Yes," state number and title)

 Number:                                   Title:
3. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR                                                         New Investigator                No           Yes
3a. NAME (Last, first, middle)                                                                      3b. DEGREE(S)                       3h. eRA Commons User Name


3c. POSITION TITLE                                                                                  3d. MAILING ADDRESS (Street, city, state, zip code)


3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT


3f. MAJOR SUBDIVISION


3g. TELEPHONE AND FAX (Area code, number and extension)                                             E-MAIL ADDRESS:
TEL:                           FAX:
4. HUMAN SUBJECTS4b. Human Subjects Assurance No.                                                  5. VERTEBRATE ANIMALS                                                  Yes
                                                                                                                                                             No
  RESEARCH                                 FWA                             00002876
                                4c. Clinical Trial     4d. NIH-defined Phase III                  5a.       If "Yes," IACUC approval Date       5b. Animal welfare assurance no
       No           Yes
                                     No      Yes       Clinical Trial          No        Yes
4a. Research Exempt                                                                                                                                           A3394-01
       No           Yes          If "Yes," Exemption No.
6. DATES OF PROPOSED PERIOD OF                                  7. COSTS REQUESTED FOR INITIAL                                8. COSTS REQUESTED FOR PROPOSED
   SUPPORT (month, day, year--MM/DD/YY)                            BUDGET PERIOD                                                 PERIOD OF SUPPORT
From                            Through                          7a. Direct Costs ($)             7b. Total Costs ($)         8a. Direct Costs ($)          8b. Total Costs ($)

                                                                               0                                0                           0                             0
 9. APPLICANT ORGANIZATION                                                                        10. TYPE OF ORGANIZATION
 Name        The Curators of the University of Missouri                                                   Public:                  Federal        X State             Local
 Address     Office of Sponsored Program Administration                                                   Private:                 Private Nonprofit
             University of Missouri-Columbia                                                              For-profit:           General               Small Business
             310 Jesse Hall                                                                               Woman-owned           Socially and Economically Disadvantaged
             Columbia, MO 65211                                                                    11. ENTITY IDENTIFICATION NUMBER

                                                                                                                                1 43-6003859 B4
Institutional Profile File Number (if known)                 DUNS NO. 153890272        Cong. District                                                                               9
 12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE 13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
 Name    Michael J. Warnock                                                                         Name            Dona R. McKinney
 Title   Director                                                                                   Title           Associate Director
 Address Office of Sponsored Program Administration                                                 Address         Office of Sponsored Program Administration
         University of Missouri-Columbia                                                                            University of Missouri-Columbia
         310 Jesse Hall                                                                                             310 Jesse Hall
         Columbia, MO 65211                                                                                         Columbia, MO 65211
 Tel    573-882-7560                                     FAX    573-884-4078                        Tel             573-882-7560       FAX 573-884-4078
 E-Mail grantsdc@missouri.edu                                                                       E-Mail          grantsdc@missouri.edu
15. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify                                 SIGNATURE OF OFFICIAL NAMED IN 13.                                  DATE
that the statements herein are true, complete and accurate to the best of my knowledge,         (In ink. "Per" signature not acceptable.)
and accept the obligation to comply with Public Health Service terms and conditions if a
grant is awarded as a result of this application. I am aware that any false, fictitious, or
fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.



PHS 398 (Rev. 04/06)                                                                         Face Page                                                                Form Page 1
              Principal Investigator/Program Director (Last, first, middle):
                                                                                    FROM                    THROUGH
    DETAILED BUDGET FOR INITIAL BUDGET PERIOD
                DIRECT COSTS ONLY
PERSONNEL (Applicant organization only)             Months Devoted to Project         DOLLAR AMOUNT REQUESTED (omit cents)
                                                                      INST.BAS
                                    ROLE ON          Cal. Acad. Sum.     E     SALARY              FRINGE
            NAME                    PROJECT         Mnths Mnths Mnths SALARY REQUESTED            BENEFITS        TOTAL
                                  Principal
                                  Investigator           0        0        0    0             0             0                0

                                                         0        0        0    0             0             0                0

                                                         0        0        0    0             0             0                0

                                                         0        0        0    0             0             0                0

                                                         0        0        0    0             0             0                0

                                                         0        0        0    0             0             0                0

                                                         0        0        0    0             0             0                0
                                  SUBTOTALS                                                   0             0                0
CONSULTANT COSTS

                                                                                                                             0
EQUIPMENT (Itemize)



                                                                                                                             0
SUPPLIES (Itemize by category)




                                                                                                                             0
TRAVEL

                                                                                                                             0
PATIENT CARE COSTS                INPATIENT                                                                                  0
                                  OUTPATIENT                                                                                 0
ALTERATIONS AND RENOVATIONS (Itemize by category)

                                                                                                                             0
OTHER EXPENSES (Itemize by category)




                                                                                                                             0
CONSORTIUM/CONTRACTUAL COSTS                                                               DIRECT COSTS
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)                                                         0
CONSORTIUM/CONTRACTUAL COSTS                                  FACILITIES AND ADMINISTRATIVE COSTS                            0
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)                                                            0
PHS 398 (Rev. 04/06)                                 Page                                                       Form Page 4
                                   Principal Investigator/Program Director (Last, first, middle):



                                              BUDGET FOR ENTIRE PROPOSED PROJECT PERIOD
                                              DIRECT COSTS ONLY
                                     INITIAL BUDGET
                                                                                    ADDITIONAL YEARS OF SUPPORT REQUESTED
        BUDGET CATEGORY                  PERIOD
           TOTALS                   (from Form Page 4)             2nd                    3rd                 4th                  5th
PERSONNEL: Salary and
fringe benefits. Applicant
organization only.                                      0                     0                     0                  0                  0
CONSULTANT COSTS
                                                        0                     0                     0                  0                  0
EQUIPMENT
                                                        0                     0                     0                  0                  0
SUPPLIES
                                                        0                     0                     0                  0                  0
TRAVEL
                                                        0                     0                     0                  0                  0
PATIENT           INPATIENT                             0                     0                     0                  0                  0
CARE
COSTS             OUTPATIENT                            0                     0                     0                  0                  0
ALTERATIONS AND
RENOVATIONS
                                                        0                     0                     0                  0                  0
OTHER EXPENSES
                                                        0                     0                     0                  0                  0
CONSORTIUM/
CONTRACTUAL              DIRECT
COSTS                                                   0                     0                     0                  0                  0
  SUBTOTAL DIRECT COSTS
  (Sum = Item 8a, Face Page)
                                                        0                     0                     0                  0                  0
CONSORTIUM/
CONTRACTUAL              F&A
COSTS                                                   0                     0                     0                  0                  0
TOTAL DIRECT COSTS
                                                        0                     0                     0                  0                  0

TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD                                                                      $              0
JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.                     $
    For all Years: Explain Period:
   From Budget for Entire and justify purchase of major equipment, unusual supplies requests, patient care or decrease in any category
                                 Identify with an asterisk (*) on this page and justify any significant increase costs, alterations and




PHS 398 (Rev. 04/06)                                        Page                                                                Form Page 5
                              Principal Investigator/Program Director (Last, first, middle):

                                                                   CHECKLIST
TYPE OF APPLICATION (Check all that apply.)
       NEW application. (This application is being submitted to the PHS for the first time.)

       REVISION/RESUBMISSION of application number:
      (This application replaces a prior unfunded version of a new, competing continuation, or supplemental application.)
                                                                                                INVENTIONS AND PATENTS
       COMPETING CONTINUATION of grant number:                                                  (Competing continuation appl. and Phase II only)
      (This application is to extend a funded grant beyond its current project period.)                                         Previously reported
                                                                                                      No
       SUPPLEMENT to grant number:                                                                   Yes. If "Yes,"            Not previously reported
       (This application is for additional funds to supplement a currently funded grant.)
      CHANGE of principal investigator/program director.
        Name of former principal investigator/program director:
       CHANGE of Grantee Institution. Name of former institution:
                                                                                    List Country(ies)
       FOREIGN application            Domestic Grant with foreign involvement       Involved:

1. PROGRAM INCOME (See instructions.)
All applications must indicate whether program income is anticipated during the period(s) for which grant support is requested.
If program income is anticipated, use the format below to reflect the amount and source(s).
            Budget Period                   Anticipated Amount                                                    Source(s)




2. ASSURANCES/CERTIFICATIONS (See instructions.)                            •Debarment and Suspension •Drug- Free Workplace (applicable to
In signing the application Face Page, the authorized organizational         new [Type 1] or revised/resubmission [Type 1] applications only)
representative agrees to comply with the following policies,                •Lobbying •Non-Delinquency on Federal Debt •Research Misconduct
assurances and/or certifications when applicable. Descriptions of           •Civil Rights
individual assurances/certifications are provided in Part III. If unable    (Form HHS 441 or HHS 690) •Handicapped Individuals (Form HHS
to certify compliance, where applicable, provide an explanation and         641 or HHS 690) •Sex Discrimination (Form HHS 639-A or HHS 690)
place it after this page.                                                   •Age Discrimination (Form HHS 680 or HHS 690) •Recombinant DNA
•Human Subjects •Research Using Human Embryonic Stem Cells•                 Research, Including Human Gene Transfer Research •Financial
•Research on Transplantation of Human Fetal Tissue •Women and               Conflict of Interest •Smoke Free Workplace •Prohibited Research
Minority Inclusion Policy •Inclusion of Children Policy• Vertebrate         •Select Agents •PI Assurance
Animals•


3. FACILITIES AND ADMINISTRATION COSTS (F&A)/ INDIRECT COSTS. See specific instructions.

       DHHS Agreement dated:                           10/15/2003                                 No Facilities and Administrative Costs Requested.
  x
       DHHS Agreement being negotiated with                                                               Regional Office.

       No DHHS Agreement, but rate established with
                                                                                                      Date
CALCULATION* (The entire grant application, including the Checklist, will be reproduced and provided to peer reviewers as confidential information.)
a. Initial budget period:            Amount of base $                          x Rate applied        0.47    % = F&A costs          $

b. 02 year                           Amount of base $                          x Rate applied        0.47    % = F&A costs          $                 0
c. 03 year                           Amount of base $                          x Rate applied        0.47    % = F&A costs          $                 0
d. 04 year                           Amount of base $                          x Rate applied        0.47    % = F&A costs          $                 0
e. 05 year                           Amount of base $                          x Rate applied        0.47    % = F&A costs          $                 0
                                                                                                             TOTAL F&A Costs $                        0
*Check appropriate box(es):
      Salary and wages base                                 Modified total direct cost base                      Other base (Explain)
      Off-site, other special rate, or more than one rate involved (Explain)

Explanation (Attach separate sheet, if necessary.) :


                                           X Yes
PHS 398 (Rev. 04/06)                                               Page                                                        Checklist Form Page