Attachment 14_NIH2043 - Proposal Summary and Data Record.pdf
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- Solicitation number
- 75N93025R00013
About this file
The document is a NIH Proposal Summary and Data Record form (NIH-2043) used for submitting a research proposal to the National Institutes of Health. The form is designed to capture comprehensive details about a potential research contract, including contract type options (cost-reimbursement, fixed price, cost-plus fixed-fee), project duration, and preliminary research information. The form requires specific details about the proposing organization, investigators, contract negotiation and execution authorities, and critical research compliance information such as human subjects research status and vertebrate animal usage.
Key sections of the form include fields for specifying subcontractor involvement, principal investigator details, estimated project hours, potential human subjects research considerations (with IRB review status), and vertebrate animal research details. The form also includes spaces for tracking amendments to the Request for Proposal (RFP), identifying the cognizant government audit agency, reporting the organization's employee count and business volume, and providing signature sections for the principal investigator and business representative. This specific form is linked to NIH Solicitation Number 75N93025R00013 for Medical Residents at NIH's Clinical Center, indicating it is part of a broader recruitment and research contract opportunity.
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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 .