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.
Principal Investigator (PI)/Contact PI
Please check if this is a Multiple PI project (as defined by NIH)
Other Multiple PIs/Co-PIs:
Funding Op (Number/Title)
Award mechanism (R01, K08, CAREER)
Proposed Start Date
Total Project Budget Requested
Current UR Financials FAO (if applicable): GR_____________
F&A (Indirect) Rate
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”)
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?
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
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
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?
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
in foreign countries? Country name: ____________________
Is any program income anticipated under this project?
Will the work involve the transfer of technology and/or
Do you have consulting arrangements, line
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
Have you submitted an annual conflict of interest
(Signature or initials of this individual recommended)
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.
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: _______
(required for Medical Center if “Yes” has been checked on consideration 2 above)
Form Rev 01/01/15
For ORPA use only:
ORPA RA: ____________________________________________________________________________