05_Proposal_Summary_NIH2043.pdf
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- Attached to
- Research Services Section Support 2. 0 for the National Center for Translational Sciences (NCATS)
- Solicitation number
- 75N95020R00028
About this file
This document contains a proposal summary form and related federal contract opportunity. The proposal summary form requests information from offerors such as the legal name and address, place of performance, estimated costs and timeline, details of any subcontractors, key personnel, and assurances related to human subjects research. The related federal contract opportunity is solicitation number 75N95020R00028 to provide day-to-day support services for the National Center for Translational Sciences, including laboratory management and support, scientific program and project management, cheminformatics, bioinformatics, computational services, scientific research support, and end user support. The agency is the Department of Health and Human Services National Institutes of Health National Institute on Drug Abuse.
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Text version
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
NATIONAL INSTITUTES OF HEALTH
PROPOSAL SUMMARY AND DATA RECORD
PROJECT TITLE (Title or RFP or Contract Proposal)
RFP/CONTRACT NUMBER
LEGAL NAME AND ADDRESS OF OFFEROR PLACE OF PERFORMANCE (Full address including ZIP)
TYPE OF CONTRACT PROPOSED
� COST-REIMBURSEMENT � FIXED PRICE
ESTIMATED TIME REQUIRED TO COMPLETE PROJECT
ESTIMATED DIRECT COSTS IN PROPOSED YEAR (From Budget
� COST-PLUS-FIXED-FEE
PROPOSED STARTING DATE
� OTHER
DOES THIS PROPOSAL INCLUDE A SUBCONTRACT � YES � NO (If yes, please furnish name and location of organization, description of services, basis for selection, responsible person employed by subcontractor and cost information.)
NAME AND TITLE OF PRINCIPAL INVESTIGATOR SOCIAL SECURITY
NO.
EST. HOURS
WEEKLY
AREA
CODE/TEL.NO.
NAME AND TITLE OF CO-INVESTIGATOR (Use attachment if necessary.)
NAME AND TITLE OF INDIVIDUAL(S) AUTHORIZED TO
NEGOTIATE CONTRACTS
AREA CODE/TELEPHONE NUMBER
NAME AND TITLE OF INDIVIDUAL(S) AUTHORIZED TO
EXECUTE CONTRACTS
AREA CODE/TELEPHONE NUMBER
DOES THIS PROPOSAL INVOLVE EXPERIMENTS WITH HUMAN SUBJECTS � YES � NO
Institution’s General Assurance re: Human Subjects DATE APPROVED � PENDING Institution’s Review Board’s Approval of this Proposal DATE APPROVED � PENDING An example of the informed consent for this study is enclosed � YES � NO A Clinical Protocol is enclosed � YES � NO
OFFEROR’S ACKNOWLEDGMENT OF AMENDMENTS TO THE RFP (Use attachment if necessary)
ERRATA NUMBER DATE ERRATA NUMBER DATE
NAME, ADDRESS, AND PHONE NUMBER OF
COGNIZANT GOVERNMENT AUDIT AGENCY
NUMBER OF EMPLOYEES CURRENTLY EMPLOYED
DOLLAR VOLUME OF BUSINESS PER ANNUM
THIS OFFER EXPIRES DAYS FROM THE
DATE OF THIS OFFER (120 days if not specified)
FOR THE INSTITUTION
SIGNATURE OF PRINCIPAL INVESTIGATOR SIGNATURE OF BUSINESS REPRESENTATIVE
TYPED NAME AND TITLE TYPED NAME AND TITLE
EMPLOYER IDENTIFICATION NUMBER DATE OF OFFER
NIH-2043
June 1982
Proposal Summary Attachment 5
Provision of the Social Security Number is voluntary. Social Security
Numbers are requested for the purpose of accurate and efficient identification, review, and management of NIH Extramural Programs.
Authority for requesting this information is provided by Title III, Section
301, and Title IV of the Public Health Service Act, as amended.
NIH-2043
June 1982
Proposal Summary Attachment 5
| RFPCONTRACT NUMBER: |
| LEGAL NAME AND ADDRESS OF OFFEROR: |
| PLACE OF PERFORMANCE Full address including ZIP: |
| ESTIMATED DIRECT COSTS IN PROPOSED YEAR From Budget: |
| PROPOSED STARTING DATE: |
| NAME AND TITLE OF PRINCIPAL INVESTIGATOR: |
| SOCIAL SECURITY NONAME AND TITLE OF COINVESTIGATOR Use attachment if necessary: |
| EST HOURS WEEKLYNAME AND TITLE OF COINVESTIGATOR Use attachment if necessary: |
| AREA CODETELNONAME AND TITLE OF COINVESTIGATOR Use attachment if necessary: |
| NAME AND TITLE OF INDIVIDUALS AUTHORIZED TO NEGOTIATE CONTRACTS: |
| AREA CODETELEPHONE NUMBER: |
| NAME AND TITLE OF INDIVIDUALS AUTHORIZED TO EXECUTE CONTRACTS: |
| AREA CODETELEPHONE NUMBER_2: |
| DATE APPROVED: |
| DATE APPROVED_2: |
| ERRATA NUMBER: |
| DATE: |
| ERRATA NUMBER_2: |
| DATE_2: |
| NAME ADDRESS AND PHONE NUMBER OF COGNIZANT GOVERNMENT AUDIT AGENCY: |
| NUMBER OF EMPLOYEES CURRENTLY EMPLOYED: |
| DOLLAR VOLUME OF BUSINESS PER ANNUM: |
| THIS OFFER EXPIRES: |
| SIGNATURE OF PRINCIPAL INVESTIGATOR: |
| SIGNATURE OF BUSINESS REPRESENTATIVE: |
| TYPED NAME AND TITLE: |
| TYPED NAME AND TITLE_2: |
| EMPLOYER IDENTIFICATION NUMBER: |
| DATE OF OFFER: |
| Project Title (Title or RFP or Contract Proposal: |
| Type of Contract-CR: Off |
| Type of Contract-FP: Off |
| Type of Contract-CPFF: Off |
| Type of Contract-Other: Off |
| Estimated Time to Complete Project: |
| Subcontract?: NO |
| Subcontract Name, address & Contact Information: |
| Social Security Number: |
| Estimated Hours for the PI: |
| Telephone Number - PI: |
| Name & Title of Co-Investigator: |
| Human Subjects?: Off |
| Pending-Assurance: Off |
| Pending-IRB: Off |
| Clinical Protocol Enclosed?: Off |
| Informed consent Enclosed?: Off |
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