Grant Application Package

Transcription

1 Opportunity Title: Offering Agency: CFDA Number: CFDA Description: Opportunity Number: Competition ID: Opportunity Open Date: Opportunity Close Date: Agency Contact: Grant Application Package Reducing Health Disparities Among Minority and Underser National Institutes of Health PA FORMS-C 01/05/ /07/2017 era Commons Help Desk Monday to Friday 7 am to 8 pm ET helpdesk@od.nih.gov Phone: All fields that are yellow with a red border or marked with a * are mandatory and must be completed before submission. Filing name can be any name that will help identify the application package after submission thru Grants.gov. This opportunity is only open to organizations, applicants who are submitting grant applications on behalf of a company, state, local or tribal government, academia, or other type of organization. Application Filing Name: John Doe NIH Grant Application V1 Select Forms to Complete Mandatory All mandatory documents must be completed. SF424 (R & R) PHS 398 Research Plan PHS 398 Cover Page Supplement Research and Related Senior/Key Person Profile (Expanded) Research And Related Other Project Information Project/Performance Site Location(s) Optional R & R Subaward Budget Attachment(s) Form 5 YR 30 ATT Planned Enrollment Report PHS 398 Cumulative Inclusion Enrollment Report PHS 398 Modular Budget Research & Related Budget Instructions Show Instructions >> Planned Enrollment Report is required if if Human Subjects was marked "yes" on the R&R Other Project Information form. The Research & Related Budget Box should been checked to enable completion of the detailed budget portion of the proposal. This electronic grants application is intended to be used to apply for the specific Federal funding opportunity referenced here. If the Federal funding opportunity listed is not the opportunity for which you want to apply, close this application package by clicking on the "Cancel" button at the top of this screen. You will then need to locate the correct Federal funding opportunity, download its application and then apply.

2 APPLICATION FOR FEDERAL ASSISTANCE SF 424 (R&R) 3. DATE RECEIVED BY STATE State Application Identifier OMB Number: Expiration Date: 6/30/ TYPE OF SUBMISSION 4. a. Federal Identifier Pre-application Application Changed/Corrected Application b. Agency Routing Identifier 2. DATE SUBMITTED Applicant Identifier c. Previous Grants.gov Tracking ID 5. APPLICANT INFORMATION Organizational DUNS: Legal Name: Department: University of Illinois Urbana-Champaign Street1: 1901 S. First Street, Suite A Street2: City: Champaign Division: County / Parish: te the legal name that should be used for NIH proposals. State: IL: Illinois Province: Country: USA: UNITED STATES ZIP / Postal Code: Person to be contacted on matters involving this application Prefix: First Name: David Middle Name: W. Last Name: Richardson Suffix: Position/Title: AVCR/Director Street1: 1901 S. First Street, Suite A Street2: City: Champaign County / Parish: State: IL: Illinois Country: USA: UNITED STATES Phone Number: Fax Number: osp@illinois.edu 6. EMPLOYER IDENTIFICATION (EIN) or (TIN): A6 Province: ZIP / Postal Code: te the EIN for NIH proposals is slightly different from our standard EIN. 7. TYPE OF APPLICANT: Other (Specify): H: Public/State Controlled Institution of Higher Education Small Business Organization Type Women Owned Socially and Economically Disadvantaged 8. TYPE OF APPLICATION: New Resubmission Renewal Continuation Revision If Revision, mark appropriate box(es). A. Increase Award B. Decrease Award C. Increase Duration D. Decrease Duration E. Other (specify): Is this application being submitted to other agencies? What other Agencies? 9. NAME OF FEDERAL AGENCY: National Institutes of Health 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: TITLE: 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: "Title of the Research Project Entered Here" 12. PROPOSED PROJECT: Start Date Ending Date 01/01/ /31/201 IL CONGRESSIONAL DISTRICT OF APPLICANT

3 SF 424 (R&R) APPLICATION FOR FEDERAL ASSISTANCE Page PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION Prefix: First Name: John Middle Name: Last Name: Position/Title: Doe Assistant Professor Suffix: Organization Name: University of Illinois Urbana-Champaign Department: Chemistry Division: Street1: 234 E. Green Street Street2: City: Champaign County / Parish: State: IL: Illinois Province: Country: Phone Number: USA: UNITED STATES ZIP / Postal Code: Fax Number: johndoe@illinois.edu 15. ESTIMATED PROJECT FUNDING a. Total Federal Funds Requested 9 b. Total n-federal Funds 0.00 c. Total Federal & n-federal Funds 0 d. Estimated Program Income 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER PROCESS? a. YES THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER PROCESS FOR REVIEW ON: DATE: b. NO PROGRAM IS NOT COVERED BY E.O ; OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW 17. By signing this application, I certify (1) to the statements contained in the list of certifications* and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances * and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious. or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001) I agree *The list of certifications and assurances, or an Internet site where you may obtain this list, is contained in the announcement or agency specific instructions. 18. SFLLL (Disclosure of Lobbying Activities) or other Explanatory Documentation 19. Authorized Representative Prefix: First Name: Walter Middle Name: K. Last Name: Position/Title: Organization: Department: Street1: Street2: Knorr Comptroller University of Illinois Urbana-Champaign Division: 1901 S. First Street, Suite A Suffix: City: Champaign County / Parish: State: IL: Illinois Province: Country: Phone Number: USA: UNITED STATES ZIP / Postal Code: Fax Number: osp@illinois.edu Signature of Authorized Representative Completed on submission to Grants.gov Date Signed Completed on submission to Grants.gov 20. Pre-application 21. Cover Letter Attachment

4 PHS 398 Research Plan Please attach applicable sections of the research plan, below. OMB Number: Introduction to Application (for RESUBMISSION or REVISION only) 2. Specific Aims Specific_Aims.pdf 3. *Research Strategy 4. Progress Report Publication List Research_Strategy.pdf Human Subjects Sections 5. Protection of Human Subjects Attachments must be provided in all three fields if Human Subjects was marked "yes" on the R&R Other Project Information form. Protection_of_Human_Subject 6. Inclusion of Women and Minorities 7. Inclusion of Children Other Research Plan Sections 8. Vertebrate Animals Inclusion_of_Women_and_Mino Inclusion_of_Children.pdf Attachment required if Vertebrate Animals marked "yes" on R&R Other Project Information form. Vertebrate_Animals.pdf 9. Select Agent Research 10. Multiple PD/PI Leadership Plan 11. Consortium/Contractual Arrangements 12. Letters of Support 13. Resource Sharing Plan(s) Resource_Sharing_Plan.pdf Appendix (if applicable) 14. Appendix s Remove Attachments s Review specific FOA to determine if a Resource Sharing Plan is required. Plans are often required if budget request is over a specified threshold.

5 PHS 398 Cover Page Supplement OMB Number: Project Director / Principal Investigator (PD/PI) Prefix: *First Name: John Middle Name: *Last Name: Suffix: Doe 2. Human Subjects Clinical Trial? This section must be completed if Human Subjects was marked "yes" on the R&R Other Project Information Form. *Agency-Defined Phase III Clinical Trial? 3. *Disclosure Permission Statement It is at the PI's discretion to allow disclosure. If this application does not result in an award, is the Government permitted to disclose the title of your proposed project, and the name, address, telephone number and address of the official signing for the applicant organization, to organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment)? 4. *Program Income *Is program income anticipated during the periods for which the grant support is requested? If you checked "yes" above (indicating that program income is anticipated), then use the format below to reflect the amount and source(s). Otherwise, leave this section blank. *Budget Period *Anticipated Amount ($) *Source(s)

6 PHS 398 Cover Page Supplement 5. Human Embryonic Stem Cells *Does the proposed project involve human embryonic stem cells? If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list: Or, if a specific stem cell line cannot be referenced at this time, please check the box indicating that one from the registry will be used: Cell Line(s): Specific stem cell line cannot be referenced at this time. One from the registry will be used. 6. Inventions and Patents (For renewal applications only) *Inventions and Patents: If the answer is "" then please answer the following: *Previously Reported: 7. Change of Investigator / Change of Institution Questions Change of principal investigator / program director Name of former principal investigator / program director: Prefix: *First Name: Middle Name: *Last Name: Suffix: Change of Grantee Institution *Name of former institution:

7 RESEARCH & RELATED Senior/Key Person Profile (Expanded) OMB Number: Expiration Date: 6/30/2016 PROFILE - Project Director/Principal Investigator Prefix: * First Name: John Middle Name: * Last Name: Doe Suffix: Position/Title: Assistant Professor Department: Chemistry Organization Name: University of Illinois Urbana-Champaign Division: * Street1: 234 E. Green Street Street2: * City: Champaign County/ Parish: * State: IL: Illinois Province: * Country: USA: UNITED STATES * Zip / Postal Code: * Phone Number: Fax Number: * johndoe@illinois.edu Credential, e.g., agency login: JOHN_DOE * Project Role: PD/PI Other Project Role Category: Commons ID must be listed for all personnel in the PD/PI role. Degree Type: Degree Year: PhD 2001 *Attach Biographical Sketch Attach Current & Pending Support Biosketch.pdf PROFILE - Senior/Key Person 1 Prefix: * First Name: Jane Middle Name: * Last Name: Smith Suffix: Position/Title: Professor Organization Name: University of Illinois Urbana-Champaign * Street1: 100 Green St. Street2: Department: Chemistry Division: This field is required by NIH, even though it is not marked as mandatory. * City: Champaign County/ Parish: * State: IL: Illinois Province: * Country: USA: UNITED STATES * Zip / Postal Code: * Phone Number: Fax Number: * janesmith@illinois.edu Credential, e.g., agency login: JANE_SMITH * Project Role: Co-Investigator Other Project Role Category: Degree Type: Degree Year: Attach Biographical Sketch Attach Current & Pending Support Co-Investigator should be used in place of Co-PI. Biosketch.pdf Delete Entry Next Person To ensure proper performance of this form; after adding 20 additional Senior/ Key Persons; please save your application, close the Adobe Reader, and reopen it.

8 RESEARCH & RELATED Other Project Information OMB Number: Expiration Date: 6/30/ Are Human Subjects Involved? 1.a. If YES to Human Subjects Is the Project Exempt from Federal regulations? If yes, check appropriate exemption number If no, is the IRB review Pending? IRB Approval Date: Human Subject Assurance Number: 4 2. Are Vertebrate Animals Used? 2.a. If YES to Vertebrate Animals Is the IACUC review Pending? Human Subjects and Vertebrate Animals are project specific. If marked "yes", additional materials are needed on the PHS 398 Research Plan page. IACUC Approval Date: Animal Welfare Assurance Number: A Is proprietary/privileged information included in the application? 4.a. Does this Project Have an Actual or Potential Impact - positive or negative - on the environment? 4.b. If yes, please explain: 4.c. If this project has an actual or potential impact on the environment, has an exemption been authorized or an environmental assessment (EA) or environmental impact statement (EIS) been performed? 4.d. If yes, please explain: 5. Is the research performance site designated, or eligible to be designated, as a historic place? 5.a. If yes, please explain: 6. Does this project involve activities outside of the United States or partnerships with international collaborators? 6.a. If yes, identify countries: 6.b. Optional Explanation: The Summary should be no more than 30 lines of text and the Narrative should only be 2-3 sentences. 7. Project Summary/Abstract Summary.pdf 8. Project Narrative Narrative.pdf 9. Bibliography & References Cited References.pdf 10. Facilities & Other Resources Facilities.pdf 11. Equipment Equipment.pdf 12. Other Attachments s s s All attachments must be in PDF format. Review specific RFP to determine if additional attachments are required beyond those listed here.

9 Project/Performance Site Location(s) OMB Number: Expiration Date: 9/30/2016 Project/Performance Site Primary Location Organization Name: DUNS Number: * Street1: Street2: * State: Province: * Country: USA: UNITED STATES I am submitting an application as an individual, and not on behalf of a company, state, local or tribal government, academia, or other type of organization. University of Illinois Urbana-Champaign S. Wright Street * City: Urbana County: Champaign IL: Illinois Although this field is not marked as mandatory, it is a required field for NIH. This address should always be used for the Performance Site. * ZIP / Postal Code: * Project/ Performance Site Congressional District: IL-013 Project/Performance Site Location Organization Name: 1 I am submitting an application as an individual, and not on behalf of a company, state, local or tribal government, academia, or other type of organization. DUNS Number: * Street1: Street2: * City: County: * State: Province: * Country: USA: UNITED STATES * ZIP / Postal Code: * Project/ Performance Site Congressional District: Additional Location(s)

10 RESEARCH & RELATED BUDGET - Budget Period 1 OMB Number: Expiration Date: 6/30/2016 ORGANIZATIONAL DUNS: Enter name of Organization: University of Illinois Urbana-Champaign Budget Type: A. Senior/Key Person Project Subaward/Consortium Project role for all personnel in the PD/PI role must be listed as "PD/PI" Prefix First Middle Last Suffix Base Salary ($) Budget Period: 1 Start Date: 01/01/2014 End Date: 12/31/2014 Months Cal. Acad. Sum. Effort Greater than 0 must be listed. Requested Salary ($) Fringe Benefits ($) Funds Requested ($) John Doe 50, , , , Project Role: PD/PI Jane Smith 70, , , , Project Role: Co-Investigator Additional Senior Key Persons: Total Funds requested for all Senior Key Persons in the attached file Total Senior/Key Person 19, B. Other Personnel Number of Personnel Project Role Cal. Months Acad. Sum. Requested Salary ($) Fringe Benefits ($) Funds Requested ($) 1 Post Doctoral Associates , , , Graduate Students Undergraduate Students Secretarial/Clerical , , , Research Technician , , , Total Number Other Personnel Total Other Personnel 162, Total Salary, Wages and Fringe Benefits (A+B) 181,832.00

11 C. Equipment Description List items and dollar amount for each item exceeding $5,000 Equipment item Funds Requested ($) High Resolution Microscope 50, Additional Equipment: Total funds requested for all equipment listed in the attached file Total Equipment 50, D. Travel 1. Domestic Travel Costs ( Incl. Canada, Mexico and U.S. Possessions) 2. Foreign Travel Costs Funds Requested ($) 6, , Total Travel Cost 10, E. Participant/Trainee Support Costs 1. Tuition/Fees/Health Insurance 2. Stipends 3. Travel 4. Subsistence 5. Other Funds Requested ($) Number of Participants/Trainees Total Participant/Trainee Support Costs

12 F. Other Direct Costs Funds Requested ($) 1. Materials and Supplies 14, Publication Costs 1, Consultant Services 4. ADP/Computer Services 5. Subawards/Consortium/Contractual Costs 6. Equipment or Facility Rental/User Fees 8, Alterations and Renovations Tuition Remission 27, Total Other Direct Costs 50, G. Direct Costs Funds Requested ($) Total Direct Costs (A thru F) 292, H. Indirect Costs Indirect Cost Type Indirect Cost Rate (%) Indirect Cost Base ($) Funds Requested ($) MTDC , , Total Indirect Costs 126, Cognizant Federal Agency (Agency Name, POC Name, and POC Phone Number) ONR, Beth Snyder 5755 I. Total Direct and Indirect Costs Funds Requested ($) Total Direct and Indirect Institutional Costs (G + H) 419, J. Fee Funds Requested ($) K. Budget Justification (Only attach one file.) Budge ustification.pdf

13 RESEARCH & RELATED BUDGET - Budget Period 2 OMB Number: Expiration Date: 6/30/2016 ORGANIZATIONAL DUNS: Enter name of Organization: University of Illinois Urbana-Champaign Budget Type: Project Subaward/Consortium Budget Period: 2 Start Date: 01/01/2015 End Date: 12/31/2015 A. Senior/Key Person Prefix First Middle Last Suffix Base Salary ($) Months Cal. Acad. Sum. Requested Salary ($) Fringe Benefits ($) Funds Requested ($) John Doe 50, , , , Project Role: PD/PI Additional Senior Key Persons: Total Funds requested for all Senior Key Persons in the attached file Total Senior/Key Person 8, B. Other Personnel Number of Personnel Project Role Cal. Months Acad. Sum. Requested Salary ($) Fringe Benefits ($) Funds Requested ($) 1 Post Doctoral Associates , , , Graduate Students Undergraduate Students Secretarial/Clerical , , , Total Number Other Personnel Total Other Personnel 111, Total Salary, Wages and Fringe Benefits (A+B) 119,840.00

14 C. Equipment Description List items and dollar amount for each item exceeding $5,000 Equipment item Funds Requested ($) Additional Equipment: Total funds requested for all equipment listed in the attached file Total Equipment D. Travel 1. Domestic Travel Costs ( Incl. Canada, Mexico and U.S. Possessions) 2. Foreign Travel Costs Funds Requested ($) 3, , Total Travel Cost 5, E. Participant/Trainee Support Costs 1. Tuition/Fees/Health Insurance 2. Stipends 3. Travel 4. Subsistence 5. Other Funds Requested ($) Number of Participants/Trainees Total Participant/Trainee Support Costs

15 F. Other Direct Costs Funds Requested ($) 1. Materials and Supplies 14, Publication Costs 1, Consultant Services 4. ADP/Computer Services 5. Subawards/Consortium/Contractual Costs 6. Equipment or Facility Rental/User Fees 7. Alterations and Renovations Tuition Remission 27, Total Other Direct Costs 42, G. Direct Costs Funds Requested ($) Total Direct Costs (A thru F) 167, H. Indirect Costs Indirect Cost Type Indirect Cost Rate (%) Indirect Cost Base ($) Funds Requested ($) MTDC , , Total Indirect Costs 82, Cognizant Federal Agency (Agency Name, POC Name, and POC Phone Number) ONR, Beth Snyder, (703) I. Total Direct and Indirect Costs Funds Requested ($) Total Direct and Indirect Institutional Costs (G + H) 249, J. Fee Funds Requested ($) K. Budget Justification (Only attach one file.) Budget ustification.pdf

16 RESEARCH & RELATED BUDGET - Budget Period 3 OMB Number: Expiration Date: 6/30/2016 ORGANIZATIONAL DUNS: Enter name of Organization: University of Illinois Urbana-Champaign Budget Type: Project Subaward/Consortium Budget Period: 3 Start Date: 01/01/2016 End Date: 12/31/2016 A. Senior/Key Person Prefix First Middle Last Suffix Base Salary ($) Months Cal. Acad. Sum. Requested Salary ($) Fringe Benefits ($) Funds Requested ($) John Doe 50, , , , Project Role: PD/PI Additional Senior Key Persons: Total Funds requested for all Senior Key Persons in the attached file Total Senior/Key Person 8, B. Other Personnel Number of Personnel Project Role Cal. Months Acad. Sum. Requested Salary ($) Fringe Benefits ($) Funds Requested ($) 1 Post Doctoral Associates , , , Graduate Students Undergraduate Students Secretarial/Clerical 1 Total Number Other Personnel Total Other Personnel 65, Total Salary, Wages and Fringe Benefits (A+B) 73,204.00

17 C. Equipment Description List items and dollar amount for each item exceeding $5,000 Equipment item Funds Requested ($) Additional Equipment: Total funds requested for all equipment listed in the attached file Total Equipment D. Travel 1. Domestic Travel Costs ( Incl. Canada, Mexico and U.S. Possessions) 2. Foreign Travel Costs Funds Requested ($) 3, , Total Travel Cost 5, E. Participant/Trainee Support Costs 1. Tuition/Fees/Health Insurance 2. Stipends 3. Travel 4. Subsistence 5. Other Funds Requested ($) Number of Participants/Trainees Total Participant/Trainee Support Costs

18 F. Other Direct Costs Funds Requested ($) 1. Materials and Supplies 4, Publication Costs 2, Consultant Services 4. ADP/Computer Services 5. Subawards/Consortium/Contractual Costs 6. Equipment or Facility Rental/User Fees 7. Alterations and Renovations Total Other Direct Costs 6, G. Direct Costs Funds Requested ($) Total Direct Costs (A thru F) 84, H. Indirect Costs Indirect Cost Type Indirect Cost Rate (%) Indirect Cost Base ($) Funds Requested ($) MTDC , , Total Indirect Costs 49, Cognizant Federal Agency (Agency Name, POC Name, and POC Phone Number) ONR, Beth Snyder, I. Total Direct and Indirect Costs Funds Requested ($) Total Direct and Indirect Institutional Costs (G + H) 133, J. Fee Funds Requested ($) K. Budget Justification (Only attach one file.) Budget ustification.pdf

19 RESEARCH & RELATED BUDGET - Cumulative Budget Section A, Senior/Key Person Section B, Other Personnel Total Number Other Personnel Total Salary, Wages and Fringe Benefits (A+B) Section C, Equipment Section D, Travel 1. Domestic 2. Foreign Section E, Participant/Trainee Support Costs 1. Tuition/Fees/Health Insurance 2. Stipends 3. Travel 4. Subsistence 5. Other 6. Number of Participants/Trainees Section F, Other Direct Costs 1. Materials and Supplies 2. Publication Costs 3. Consultant Services 4. ADP/Computer Services 5. Subawards/Consortium/Contractual Costs 6. Equipment or Facility Rental/User Fees 7. Alterations and Renovations 8. Other 1 9. Other Other 3 Section G, Direct Costs (A thru F) Section H, Indirect Costs Section I, Total Direct and Indirect Costs (G + H) Section J, Fee Totals ($) 8 12, , , , , , , , , , , , , , ,049.00