Attachment 12 - Proposal Summary and Data Record NIH2043.pdf

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

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