Fillable Proposal Sign-Off Form (Page 2 of 4) in pdf

OBTAIN FOLLOWING SIGNATURES AS APPLICABLE TO THIS PROPOSAL:

Yes

Is proposed project using space or facilities of Strong Memorial Hospital? If yes, obtain Signature of SMH Senior Director for Finance

(x5-3033 – Room 1-2412): ______

Will project require resources of the University Vivarium? If yes, please list the animal species ____________________________and the

estimated maximum number of each species housed at one time ___________and send a copy of the signoff form to the attention of the

Vivarium Director, Box 674.

Will project require resources of the CRC? If yes, obtain Signature of CRC Director:

Will project require services of the Department of Biostatistics and Computational Biology? If yes, obtain Signature of Chair, Department of

Biostatistics and Computational Biology:

E (a).Will this project include pathogens, recombinant DNA, human blood, body fluids or tissue, virus vectors, human cell lines or generation of

transgenic animals via recombinant DNA technology or interbreeding? For additional information, consult the

IBC Webpage.

E (b). Will this project involve an OSHA recognized carcinogen? (2-Acetylaminofluorene, 4-Aminodiphenyl, Benzidine, bis-Chloromethyl ether,

3,3’-Dichlorobenzidine (and its salts), 4-Dimethylaminoazo-benezene, Ethyleneimine, methyl chloromethyl ether, alpha-Naphthylamine,

beta-Naphthylamine, 4-Nitrobiphenyl, N-Nitrosodimethylamine, beta-Propiolactone)

If answer to question E(a) or E(b) is marked “Yes”, please send a copy of this completed signoff form to the attention of the IBC Program

Coordinator, Environmental Health & Safety, RC Box 278878.

Will faculty or staff from other University departments, divisions, or units participate in this project or will resources of another department,

unit or office (see below) be used? If yes, obtain signature of Participating Department Chair(s), Dean(s), or Director(s):

Faculty and Dept. Name (printed)

Signature

Faculty and Dept. Name (printed)

Signature

Faculty and Dept. Name (printed)

Signature

DESCRIPTION OF PROPOSAL SIGN-OFF RESPONSIBILITIES

PRINCIPAL INVESTIGATOR/MULTIPLE PI: The PI/Multiple PI is the initiator and director of the proposed program. The PI’s/Multiple’s PIs’ signature(s)

indicates that he/she/they will adhere to University and sponsor policies affecting the project, including completion of an Employee Intellectual Property

Agreement and conflict of interest disclosure, monitoring of expenditures and the submission of reports required by the sponsor and the University.

DEPARTMENT CHAIR, DIVISION/UNIT CHIEF: These signatures mean that agreement has been reached regarding the amount and type of departmental

resources that will be required to assist a PI in completing a project. If new space, personnel, or renovations are required, further discussion with the

appropriate Dean’s office will be necessary. This signature also confirms receipt of the annual conflict of interest disclosure and, where required, the

supplemental disclosure and certifies that review will be complete and conflicts resolved, if any, prior to award.

DEAN: The Dean’s signature means that agreement has been reached regarding the amount of School/College resources required to support the

program. The Dean ensures that appropriate salary and pooled costs are requested in the proposal. As well, the Dean participates in discussions of new

space or renovations required to complete a project.

THIRD PARTY COST SHARING: A complete Pre-Award Third Party Cost Sharing is required at the time of proposal to indicate the Third Party’s

concurrence with their cost sharing responsibilities.

ADDITIONAL REVIEW AND/OR OTHER SIGNATURES WHICH MAY BE REQUIRED DEPENDING UPON THE NATURE OF THE RESEARCH:

RESOURCES OF OTHER DEPARTMENTS, UNITS OR OFFICES: Projects that require resources of other University departments or offices require

approval of the appropriate signatory. At the Medical Center, examples include Blackboard Online Learning, Curricular Affairs/Office of Medical Education,

etc.

VIVARIUM: All University projects using animals must be reviewed by the University Committee of Animal Resources (UCAR, x5-1693).

BIOHAZARDS: Projects which propose the use of potential biohazards, including recombinant DNA and carcinogens, must be reviewed by the Executive

Secretary of the Biosafety Committee, 685 Mt Hope Ave., x5-3241. This signature is required to comply with federal and state regulations covering

biohazards.

BIOSTATISTICS AND COMPUTATIONAL BIOLOGY SERVICES: Projects that involve biostatistics services must be approved by the Department of

Biostatistics and Computational Biology, Saunders Research Bldg. Room 4106, x5-2407. This signature ensures that adequate costs and professional

effort have been included to support biostatistical studies.

STRONG MEMORIAL HOSPITAL: Projects which involve facilities, services, or training programs of Strong Memorial Hospital require the signature of the

Senior Director for Finance, Room 1-2412, Medical Center, x5-3300.

CLINICAL RESEARCH CENTER: Projects which will require beds, space, or staff of the Clinical Research Center should be reviewed by the Director of

the Clinical Research Center. Room 1.502, Saunders Research Building, x5-0674.

EXPLANATION OF THE ITEMS FROM FRONT (use additional sheets)

Form Rev. 01/01/15

Page 2

Proposal Sign-Off Form Page 2

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