Attachment 15_NIH2043 - Proposal Summary and Data Record.pdf
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- Attached to
- Amendment #3 - Solicitation Notice - Operation and Management of the Mali Service Center
- Solicitation number
- 75N93025R00007
About this file
This is NIH Form 2043, a Proposal Summary and Data Record form used by the National Institutes of Health for contract proposals. The form is designed to capture essential information about contract proposals including the project title, offeror details, type of contract (with options for cost-reimbursement, fixed price, cost-plus fixed-fee, or other), estimated completion time, proposed start date, and estimated direct costs.
The form requires detailed information about key personnel (Principal Investigator and Co-Investigators), subcontracting plans, human subjects research approvals, vertebrate animal use protocols, and institutional authorizations. It includes sections for IRB and IACUC review status, assurance numbers, and clinical protocol documentation. The form must be signed by both the Principal Investigator and an authorized business representative, and includes fields for the institution's employer identification number and acknowledgment of any amendments to the RFP. This appears to be a blank template form (revision dated 07/08) associated with NIH solicitation #75N93025R00007 for the Operation and Management of the Mali Service Center.
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Text version
DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL INSTITUTES OF HEALTH
PROPOSAL SUMMARY AND DATA RECORD
RFP NUMBER/CONTRACT NUMBER
PROJECT TITLE (Title of RFP or Contract Proposal)
LEGAL NAME AND ADDRESS OF OFFEROR PLACE OF PERFORMANCE (Full address including ZIP)
TYPE OF CONTRACT PROPOSED
COST-REIMBURSEMENT FIXED PRICE COST-PLUS FIXED-FEE OTHER
ESTIMATED TIME REQUIRED TO COMPLETE PROJECT PROPOSED STARTING DATE
ESTIMATED DIRECT COSTS IN PROPOSED YEAR (From Budget)
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.) (Use attachment if necessary.)
NAME AND TITLE OF PRINCIPAL INVESTIGATOR EST. HOURS WEEKLY AREA CODE/TEL. NO.
NAME AND TITLE OF CO-INVESTIGATOR (Use attachment if necessary) EST. HOURS WEEKLY AREA CODE/TEL. NO.
NAME AND TITLE OF INDIVIDUAL(S) AUTHORIZED TO NEGOTIATE CONTRACTS
NAME AND TITLE OF INDIVIDUAL(S) AUTHORIZED TO EXECUTE CONTRACTS
DOES THIS PROPOSAL INVOLVE HUMAN
SUBJECTS RESEARCH? YES NO EXEMPTION NUMBER (IFAPPLICABLE)
If YES to Human Subjects, is the IRB review Pending? YES NO If IRB Review Not Pending, IRB Approval Date
Human Subjects Assurance Number
An example of the informed consent for this study is enclosed YES NO N/A A Clinical Protocol is enclosed YES NO N/A
Are Vertebrate Animals Used? YES NO
If YES to Vertebrate Animals, is the IACUC review Pending? YES NO
If IACUC Review Not Pending, IRB Approval Date Animal Welfare Assurance Number
OFFEROR’S ACKNOWLEDGEMENT 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 (Rev. 07/08)
File details come from the government source that posted it. Updated .