Fillable Proposal Sign-Off Form printable pdf download

When this proposal has been signed, please call ______________________________ Extension __________

UNIVERSITY OF ROCHESTER PROPOSAL SIGN-OFF FORM

THIS FORM MUST BE COMPLETED AND SUBMITTED WITH THE PROPOSAL TO ORPA

AFTER ALL NECESSARY SIGNATURES HAVE BEEN OBTAINED.

UR Financials

Principal Investigator (PI)/Contact PI

Company

Cost Center

Please check if this is a Multiple PI project (as defined by NIH)

Other Multiple PIs/Co-PIs:

Project Sponsor

Project Title

Funding Op (Number/Title)

Award mechanism (R01, K08, CAREER)

Proposed Start Date

End Date

Total Project Budget Requested

Deadline

Proposal Type:

New

Continuation

Supplement

Resubmission

Renewal

Current UR Financials FAO (if applicable): GR_____________

F&A (Indirect) Rate

Award Type:

Grant

Contract

Subcontract/subaward

Purpose:

Research

Clinical Research

Training

Fellowship

Service

Other

Project Location:

On-Campus

Off-Campus

If off-campus, location

ADMINISTRATIVE AND POLICY CONSIDERATIONS (MUST BE COMPLETED BY PI) - Please explain “yes” responses on additional sheets

NOTE: All Co-Investigators, and other named investigators, MUST complete Section A (“Additional Signatures Certification”)

Yes

N/A

Yes

Does this project contain a clinical research

13. If you have acquired new financial interests since your last

component with clinical procedures?

disclosure, have you reported these to the institution?

Yes No

If “Yes”, complete Section B (on page 4).

Does this project require additional/new space or

14. For NIH proposals, do all investigators agree to comply with the

renovation/modification of current space or facilities?

NIH Public Access Policy? Please see the

NIH Policy

for details.

Check all that apply:

15. Is this an Individual NRSA (F-awards) Fellowship? If yes,

Equipment/Utility support _____ Additional, New or

complete the Individual Fellow and Faculty Mentor Certification

Renovated Space _____ If yes, include an explanation

for NIH F-awards Certification

Individual Fellow and Faculty

on amount of space needed, cost and source of funds.

Mentor Certification for NIH F-awards.

Does this proposal involve cost sharing or matching

16. Are you currently debarred or suspended from doing business

funds? If yes, complete below:

with the federal government or excluded from Medicare or other

-Total Amount of cost sharing

federal/state health care programs, or are you currently in

-Type of cost being shared _____________________

default on any federal student loans?

-Planned cost share UR Financials FAO(s)

17. Have you engaged in lobbying activities using federal funds to

_________________

influence any federal employee in connection with this

-If the cost sharing is Third Party Cost Sharing, attach a

proposal?

Pre-award THIRD PARTY COST SHARING FORM

18. If funded, will other individuals be authorized to sign for

Will research use human subjects?

purchases necessary for the project? If yes, name authorized

Will research use animals?

individuals:

Will research use radioactive materials or isotopes?

Will research use human embryonic stem cells?

19. Is this proposal a collaborative inter-school/college program with

Are you requesting less than the maximum F&A costs

sharing of indirect cost recovery? If yes, attach completed copy

as allowed by the sponsor’s written policy?

of Sharing of Indirect Cost Recovery form.

Will there be subcontracts to other institutions?

20. Does the project involve international partnerships or activities

Number? _____

in foreign countries? Country name: ____________________

10.

Is any program income anticipated under this project?

21.

Will the work involve the transfer of technology and/or

11.

Do you have consulting arrangements, line

materials overseas?

management responsibilities, substantial equity

22. Identify the CLASP-certified individual(s) who will have

holdings with the sponsor, subcontractor, or potential

functional responsibility for oversight of this project, should it be

vendor?

funded. ____________________________________________

12.

Have you submitted an annual conflict of interest

(Signature or initials of this individual recommended)

disclosure statement?

PRINCIPAL INVESTIGATORS’ CERTIFICATION

In signing below the Principal Investigator(s) (PIs) certify that the above is accurate and complete to the best of the PIs’ knowledge. This certification

must also include signatures of all investigators in Section A (page 3 of this form). The PI certifies the proposal (including any subsequent

supplemental material) is compliant with sponsor requirements. In addition, the PI(s) understand that any false, fictitious, or fraudulent statements or claims

made in the accompanying submission may subject the PI(s) personally to criminal, civil, or administrative penalties. The PI(s) agrees 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 this application.

Principal Investigator(s):

Date:

REQUIRED SIGNATURES: (PLEASE SEE REVERSE FOR ADDITIONAL SIGNATURES WHICH MAY BE REQUIRED)

Dept Chair: _________________________________Date: _______

Cost Center Chief: ____________________________________ Date:

Director of Medical Center

Dean: _____________________________________Date: _______

Space Planning:

Date:

(required for Medical Center if “Yes” has been checked on consideration 2 above)

Form Rev 01/01/15

For ORPA use only: