PROJECT DIRECTOR / PRINCIPAL INVESTIGATOR CONTACT INFORMATION Prefix: First Name: Middle Name: Last Name: Suffix:
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1 Proposal Summary Proposal Number Sponsor Deadline Proposal Status: Submission Method: Submission Type: Pre-application Application Changed/Corrected INVESTIGATOR DATA PROJECT DIRECTOR / PRINCIPAL INVESTIGATOR CONTACT INFORMATION Prefix: First Name: Middle Name: Last Name: Suffix: Position/Title: Department: Street1: City: : Country: Organization: Division: Street2: County: Zip Code: Employee ID: Phone Number: First Budget Period Effort Fax Number: Calendar Academic Summer Status of PI: Status Waiver Required? Signed Intellectual Property Waiver Attached? Signed Conflict of Interest Disclosure Attached? Agency Certification Documentation Attached? Cost Sharing Authorization Form Attached? SPONSOR DATA Agency: Proposal Type: Sponsor Mechanism: Sponsor Type: Sponsor Name/ID: SubDivision 1: SubDivision 2: NAME OF AGENCY FEDERAL, NONFEDERAL, FOUNDATION ETC NAME OF CONTACT PERSON AT AGENCY SUBMISSION ADDRESS OR SUBMISSION ADDRESS OR
2 PROJECT DATA Title of Project: OFFICIAL TITLE OF THE PROJECT Is This a Subcontract? If, who is prime? NAME OF THE LEAD INSTITUTION Type of Proposal: Kind of Application: Type of Project: Grant Contract Fellowship Type of Agency: Federal Association Foundation Industry Other New Resubmission Renewal Continuation Revision/supplemental Previous Grant # or Federal Identifier: Basic Equipment Clinical/applied research Clinical trial Research training Instructional research Service Change in grantee institution Other PROJECT ADMINISTRATION Who is responsible for this research? PERSON DOING THE RESEARCH IF DIFFERENT FROM LEAD PI Departmental Identification Number: Primary Secondary Departmental Name: Primary Secondary Departmental Contact Information: Account Classification: Primary Secondary Other Institutional Code: NAICS Code: COMPLIANCE DATA Animal Subjects Human Subjects Are animal subjects used? Is IACUC review pending? IACUC Protocol # Approval Date Are human subjects used? Is IRB review pending? IRB Protocol # Approval Date Does this project involve use of any of the following? Radioactive Material(s), Radiation Producing Devices(s), Recombinant DNA, Biohazardous Chemical(s), Class IIIb or IV Lasers, Other certifications of health, safety and/or environmental compliance. If, Explain in attachment
3 BUDGET DATA Performance Dates Begin Date End Date Cost Sharing Information: First Year/Period: Cumulative Period: Mandatory Committed Amount: Source: Voluntary Committed Amount: Source: Budget Period Period 1 Period 2 Period 3 Period 4 Period 5 Total Direct Cost Indirect Cost Total Cost AWARD DATA Award #: Contract #: Date: Budget Period Period 1 Period 2 Period 3 Period 4 Period 5 Total Direct Cost Indirect Cost Total Cost EXPORT CONTROL 1. Will the project involve participation, collaboration or access to information by foreign nationals, defined as: individuals with foreign citizenship, foreign governments, foreign associations and corporations, or foreign political parties? te: Foreign nationals granted US citizenship, or permanent residence "green card" or granted status as a "protected individual, e.g., political refugees and political asylum holders are "EXEMPT" from deemed export rule. 2. Will the project involve the shipment of equipment, technology, software, materials data or other information? 3. Will the project involve a foreign subcontract or other foreign contractual agreement? If you answered yes to any of the above questions, please attach documentation to the Generic Upload Area describing the details of these issues for this proposal.
4 COMMENTS AND EXPLANATIONS PLEASE INDICATE ANY SPECIAL INSTRUCTIONS BELOW: IN THIS SPACE TYPE A ONE OR TWO SENTENCE DESCRIPTION OF YOUR PROJECT
5 [ ] Using Federal Reporting Federal Reporting Organization Name DUNS Congressional District Award Number Award Date Award Amount Award Amount Received Funding Agency Code Awarding Agency Code Final Report Treasury Account Symbol Treasury Sub Account Code Award Description Project Description Project Status Job Creation Number Job Creation Narrative Total Number Subawards Individuals Total Amount Subawards Individuals Total Number Small Subawards Total Amount Small Subawards Project Title CFDA Program Number Total Federal ARRA Expenditure Total Federal ARRA Infrastructure Expenditure Infrastructure Rationale Infrastructure Contact Name Address Street 1 Street 2 City Zip Code Telephone Number Telephone Extension Total Number Vendor Payments Total Amount Vendor Payments Account Number Highly Compensated Officers Primary Place Of Performance Organization Name DUNS Congressional District Address Street 1 Street 2 City County Zip Code Country OFFICIAL TITLE OF THE PROJECT Federal Reporting page 1 of 1
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