Letter Of Intent To Enter Into A Federal Subaward Or Consortium Agreement Form Page 2

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Grants Administration Policy and Procedures Manual
___ FOREIGN ENTITIES ONLY: Subawardee/Cooperating Institute will adopt Boston Medical
Center/Boston University (Prime Recipient) COI Policy but has limited English language capability. All
subrecipient “Investigators,” or, any person, regardless of title or position, who is responsible for the
design, conduct, or reporting of research, as defined by Boston University and Boston Medical Center
policy must fill out a Financial Interest Disclosure Form prior to submission of research proposal
application, and send it to Jodi Edelstein, Manager, Conflicts of Interest, Office of Research
Compliance, Boston University via email at coi@bu.edu, with “Financial Interest Disclosure Form (for
Subrecipients)” in the email subject line. After submission, all “Investigators” will receive an email
directing them to the training.
Other Certifications: By signing below, the above-named Subawardee/Cooperating Institution certifies that:
Neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from any covered transaction by any federal agency (45 CFR Part 76 and Executive Order
12549); (2) It is in compliance with the requirements of 45 CFR Part 76, Subpart F (Drug Free Workplace); (3)
It is in compliance with the requirements of 31 USC § 1352 (Lobbying); (4) It is in compliance with the
requirements of 42 CFR Part 93 (Misconduct in Science); (5) It is in compliance with Title VI of the Civil
Rights Acts of 1964, the Age Discrimination Act of 1975, Executive Order 11246 and Section 504 of the
Rehabilitation Act of 1973 as amended, and certifies that it has valid Assurances of Compliance on file with
DHHS; (6) It is in compliance with 45 CFR, Part 46, subpart A, “Protection of Human Subjects”; (7) If human
subjects research is to be performed at Cooperating Institution, it will ensure Institutional Review Board review
in compliance with 42 U.S.C. s. 289 (Health Research Extension Act of 1985) and 45 C.F.R. s. 46.103.
BOSTON MEDICAL CENTER CORPORATION.
COOPERATING INSTITUTION
____________________________
______________________________
Ellen N. Jamieson, MS, MBA
Name: ________________________
Associate Director
Title: _________________________
Grants Administration
_____________________________
Date: _________________________
Date: ________________________
Acknowledged by:
___________________________________
BMC Principal Investigator
2
08/28/12
Grants Administration

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