Attachment 7 - Proposal Summary and Data Record.pdf
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- Solicitation number
- 75N95022R00030
About this file
This document is a proposal summary and data record template for federal contract opportunities with the Department of Health and Human Services and National Institutes of Health. The template collects key details about a proposed project such as the project title, RFP or contract number, offeror information including legal name, address and place of performance. It requests information on the type of contract, estimated time and costs to complete the project, proposed start date, use of subcontractors, principal investigator details, and whether the proposal involves human subjects research. It also requires acknowledgement of any solicitation amendments and business representative signature to confirm the offer expiration date.
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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
File details come from the government source that posted it. Updated .