BAA-18-100-SOL-00003_BAA_Special_Instructions_DRIVe_Submission_Form_.pdf

DRIVe BAA Special Instructions to BAA-18-100-SOL-00003 Submission Form

Introduction All applicants for the DRIVe BAA Special Instructions must complete this Special Instructions Submission Form. For details on the funding scope, priorities and timing, please visit drive.hhs.gov and review the solicitation (BAA-18-100-SOL-00003) at Federal Business Opportunities (FBO).

If your project is in scope it will be assigned for review and you may be asked to submit a stage two full proposal package.

Note that this solicitation is for larger awards; smaller projects are encouraged to submit abstracts to our EZ-BAA (DRIVe EZ-

BAA BAA-18-100-SOL-00018)

Please note that in order to submit a proposal you must have an active registration in the System for Award Management (SAM). You can register and check your registration status at sam.gov. Full application instructions, including review criteria, can be found at in the solicitation posted on fbo.gov. Additional resources are also available on drive.hhs.gov.

IMPORTANT

Instructions and conventions

• First save this document to your local hard drive. Filling out this document on-line in your browser may lead to inconsistent behavior while filling out the form. Use Adobe Acrobat Reader DC for the best results.

• Please complete one form for each proposition.

• All fields marked with an asterisk (*) are required.

• Only fields labeled with red text should include proprietary information. All other provided information may be used and displayed publicly. Please be sure to check the 'Acknowledge' box below.

• Submission instructions are listed at the end of this document.

By clicking the following checkbox, you hereby acknowledge that proprietary information is to be entered only in the sections marked 'proprietary' (i.e. labeled with red text), and that BARDA DRIVe is not responsible for proprietary information that is entered in sections that are not marked as such.

Acknowledge *

Application ID to be filled out by DRIVe (FOUO):

SubmissionSolicitation #: BAA-18-100-SOL-00003

DRIVe BAA_Ver. 1.0 03/2019 Page 1 of 6 03/28/2019 http://drive.hhs.gov https://sam.gov http://fbo.gov http://drive.hhs.gov https://get.adobe.com/reader/ https://fbo.gov/spg/HHS/OOS/OASPHEP/BAA-18-100-SOL-00018/listing.html ic In or tion (* Denotes required field.)

IMPORTANT: All fields labeled in red contain proprietary information.

First Name *:

Middle:

Last Name *:

Email *:

Email (confirm):

If your primary work location is different from your organization’s headquarters, please enter those details below. Otherwise, leave blank except for phone number(s).You will be prompted to enter your organization’s main address on the next screen.

Office Address 1 *:

Office Address 2:

City *:

State / Province / Region *:

Zip / Postal Code*:

Country *:

Phone *:

Mobile:

A.1 How did you learn about BARDA? Check all that apply.A.1 How did you learn about BARDA? Check all that apply.

BARDA Industry Day

DRIVe Event

News article or blog

DRIVe website

DRIVe Accelerator

BARDA via medicalcountermeasures.gov or phe.gov

Advocacy group

A colleague

Social media

Scientific conference

Scientific publication

Other, describe

Application ID (FOUO):

SubmissionSolicitation #: BAA-18-100-SOL-00003

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B. Organizational Information

B.1 Address (* Denotes required field.)

Specify the legal structure of the organization applying for the DRIVe award. * (select 1)

Yes - Enter DUNS: Enter CAGE:

No - Without an active registration, your proposal cannot cannot be reviewed. Go to sam.gov to register.

NAICS Code (Click here for complete listing) *:

Business Size: *

Number of Employees *:

Annual Revenue *:

Application ID (FOUO):

Privately held company

FFRDC

Non-Governmental Organization

Non-legal entity

Publicly held company

Educational Institution

Other Non-Profit Organization

SubmissionSolicitation #: BAA-18-100-SOL-00003

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Organization Name *:

Address 1 *:

Address 2:

City *:

State / Province / Region *:

Zip / Postal Code *:

Country *:

Website:

B.2 Details (* Denotes required field.)

Business type, size, revenue, and prior award information is for survey and metrics reporting purposes only and the proposal will be based on solicitation criteria ONLY and not on this information.

Is your organization registered in the SAM? *

Minority Owned Business

Asian-Pacific American Owned

Subcontinent Asian (Asian-Indian) American Owned

Black American Owned

Hispanic American Owned

Native American Owned

Woman Owned Business

Woman Owned Small Business

Economically Disadvantaged Woman Owned Small Business

Joint Venture Woman Owned Small Business

Joint Venture Economically Disadvantaged Woman Owned Small Business

Veteran Owned Business Service Disabled Veteran Owned Business

Other

Community Development Corporation Owned Firm

Labor Surplus Area Firm

Self Certified Small Disadvantaged Business

SBA Certified 8A Program Participant

SBA Certified HUB Zone Firm

AbilityOne (formerly JWOD) Non-Profit Agency

Socio-Economic Status (Select all that apply.)

https://sam.gov https://www.sba.gov/sites/default/files/files/Size_Standards_Table.pdf

C. Current Funding Sources

Do you presently receive funding from any USG entities? * (Check all that apply.)

BARDA

CARB-X

NIAID Pre-clinical Services

NIH/NIAID/SBIR/STTR grants or contract

Centers for Disease Control and Prevention (CDC)

Other HHS

Defense Advanced Research Projects Agency (DARPA)

Defense Threat Reduction Agency (DTRA)

Defense Health Agency (DHA)

Other DoD

National Science Foundation (NSF)

Department of Energy (DOE)

Department of Homeland Security (DHS)

Intelligence Advanced Research Projects Activity (IARPA)

Small Business Administration

Other department

No US Government funding

Application ID (FOUO):

SubmissionSolicitation #: BAA-18-100-SOL-00003

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NoHave you ever been awarded a government (federal, state, local, tribal or territorial) contract or grant?

Are you currently under a grant or contract issued by BARDA? Yes No

If yes, what was the date of the most recent award?

If yes, what was the period of performance?

If yes, what was the total dollar value of the contract or grant?

Yes

Do you own or have the rights to the Intellectual Property (IP) required to carry out your proposed project? [Choose one] *

Yes – IP is fully owned

Yes – We have a fully executed license to the IP

No – If selected, please address this in your project proposal.

Not applicable – Our commercialization strategy does not rely on patents

Application ID (FOUO):

D. DRIVe Project Proposal (* Denotes required field.)

What is the title of your project? *

Which Impact Area does your application relate to? *

Please give a non-proprietary description of your project in 100 words or less. *

IMPORTANT: All fields labeled in red contain proprietary information.

Please select your product type. *

What stage of development is your project? *

What is the funding request (in US Dollars), duration of funding, cost-share proposition (if any) and impact on advancement of the program? *

Amount requested from DRIVe (must be in US Dollars): *

Proposed period of performance. Start date: End date:

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Do you believe a conflict of interest may exist in conjunction with submission of this abstract to BARDA/DRIVe? If so, please list the names of potentially conflicted individual(s) below. A contracting officer will contact you before your abstract is reviewed.

Cost-share. Anticipated target range is 30% - 50% cost-share by respondent, but will be project dependent per HHSAR 335.070.

(Provided by your organization and must be in US Dollars.): *

Total project cost (auto-calculated):

Duration (months): *

SUBMISSION INSTRUCTIONS (* Denotes required field.)

To submit your application, please perform the following steps:

• Ensure that all required fields are completed.

• Attach the additional required documents (Quad Chart, White Paper, and Addendum/ROM)

• Save a copy of this form using the 'Save' button below. Clicking 'Save' will also validate your form to ensure that you have provided all the required information.

• Attach the copy as an email attachment.

• Include the following items in the subject line of your email:

o "DRIVe Special Instructions" o AoI (Solving Sepsis or ENACT) o Your company name and project title o For example: DRIVe Special Instructions_Solving Sepsis_ACME Devices, Inc_TransformativeCountermeasureProject

• Send the email to DRIVeContracting@hhs.gov.

Once your application is received, it will be moved to a secure server where it will be reviewed by a BARDA DRIVe team member. Once received, you will no longer be able to access your application. Duplicate applications will not be accepted.

Application ID (FOUO):

SubmissionSolicitation #: BAA-18-100-SOL-00003

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