Att3_NIH Form 2043.docx
NIH Form DOCX document 35 KB Posted
- Solicitation number
- 75N96025R0003
About this file
This file is NIH Form 2043, which is a standard Proposal Summary and Data Record template used for National Institutes of Health contract proposals. The form is designed to capture key information about contract proposals including project title, legal name and address of offeror, place of performance, type of contract (with options for cost-reimbursement, fixed price, cost-plus fixed-fee, or other), estimated completion time, proposed start date, estimated direct costs, subcontract details, principal investigator information, human subjects research details, vertebrate animal research details, and business/administrative information.
This blank template form is associated with solicitation 75N96025R0003 for Pathology Support services for the National Institute of Environmental Health Sciences (NIEHS). While the form itself does not contain specific requirements or scope details, it represents required documentation that must be completed by offerors responding to this solicitation.
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Text version
Appendix G
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)
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