Att3_NIH Form 2043.pdf
NIH Form PDF 67 KB Posted
- Solicitation number
- 75N96025R00001
About this file
This is NIH Form 2043, which is a Proposal Summary and Data Record template that contractors must complete when submitting proposals in response to NIH RFP 75N96025R00001 for NIEHS Assessment of Immunotoxicity.
The form captures key proposal information including legal name/address of offeror, place of performance, contract type (cost-reimbursement, fixed price, or cost-plus fixed-fee), estimated costs, subcontractor details, principal investigator information, human subjects research details, vertebrate animal research information, acknowledgement of RFP amendments, audit agency details, and authorized negotiator/executor information. The form requires signatures from both the principal investigator and business representative, along with the employer identification number and offer expiration date (defaulting to 120 days if not specified).
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Other versions and copies of NIH Form 2043
| File | Revision | Posted | Attached to |
|---|---|---|---|
| Att3_NIH Form 2043.docx | Revision not stated | Pathology Support for the National Institute of Environmental Health Sciences | |
| Att3_Proposal Summary and Data Record NIH Form 2043.pdf | Revision not stated | Quality Assessment Support for the National Institute of Environmental Health Sciences | |
| RFP-Attachment_5-NIH_FORM_2043.pdf | Revision not stated | Conference, Logistical, Analytical and Technical Services |
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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)
File details come from the government source that posted it. Updated .