20230417 BAA ITC IPAC Atch 9 Additional Key Personnel Information.pdf

Instructions for Completion

Complete this attachment for any other key personnel/investigators who will be associated with this project.

Section 1 Complete this section with the other key personnel/investigators information.

Current & Pending Funding Provide additional information on any additional support they are receiving for this project and any other projects.

Privacy Act Completion Review and complete the “Covered Individual” and “Institution Name” Blocks.

Attachment 9 BROAD AGENCY ANNOUNCEMENT

FA520922S0001

OTHER KEY PERSONNEL/INVESTIGATOR INFORMATION

DATE:

1. OTHER KEY PERSONNEL/INVESTIGATOR INFORMATION

Prefix: First Name: Last Name:

Organization Name:

Position: Department:

Phone Number: Email:

List Degree(s) Type/Year:

List Previous Employment/Experience (include years):

List last five (5) publications and five (5) most closely related to the proposal:

CURRENT AND PENDING SUPPORT

The following information should be provided for each investigator and other senior personnel. Failure to provide the information may delay consideration of the proposal.

Investigator:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Plannedin Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

* If this project has previously been funded by another agency, please list and furnish information for immediately preceding funding period.

USE ADDITIONAL SHEETS AS NECESSARY

CURRENT AND PENDING SUPPORT

The following information should be provided for each investigator and other senior personnel. Failure to provide the information may delay consideration of the proposal.

Investigator:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Planned in Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

Support: Current Pending Submission Plannedin Near Future *Transfer of Support

Project/Proposal Title:

Source of Support:

Award Amount (or Annual Rate:) $ Period Covered:

Location of Research:

Person-Months Committed to the Project: Cal: Acad: Summer:

* If this project has previously been funded by another agency, please list and furnish information for immediately preceding funding period.

USE ADDITIONAL SHEETS AS NECESSARY

Privacy Act Statement

Army Futures Command or Department of the Army

Application for Federal Assistance

Authority: Government Paperwork Elimination Act (Pub. L. 105-277, 44 U.S.C. 3504); Executive Order 12372, Intergovernmental review of Federal Programs (47 FR 30959); 42 U.S. Code § 6605 – Disclosure of funding sources in applications for Federal research and development awards; Public Law 117-167, CHIPS and Science Act; Public Law 116-92, National Defense Authorization Act for Fiscal Year 2020; 5 U.S.C. 9101, Access to Criminal History for National Security and Other Purposes 5 CFR §1320.8, Agency collection of information Responsibility; 18 U.S.C. § 1001, False Statements, Concealment; E.O. 13478, Amendments to Executive Order 9397 Related to Federal Use of social Security Numbers; NSPM-33, National Security Presidential Memorandum 33 on National Security for United States Research and Development; DoD-D 5240.01, DoD Intelligence Activities; DoD-I 5200.02, Department of Defense Personnel Security Program; Army Regulation 381-10, U.S. Army Intelligence Activities

Purpose: The information collected may be used in processing, investigating, and maintaining records relevant to Federal Assistance awarded by the Department of the Army. Records in these systems will be used to ensure Army sponsored and/or awarded federal grants, assistance, contracts, and/or benefits are awarded to responsible parties, entities, and individuals.

Routine Uses: To contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government when necessary to accomplish an agency function.

To the appropriate Federal, State, local, territorial, tribal, foreign, or international law enforcement authority or other appropriate entity where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law, whether criminal, civil, or regulatory in nature.

DoD Blanket Routine Use (http://dpcld.defense.gov/privacy)

Effect of not providing information: Providing information to the Department of the Army is voluntary. However, 42 U.S. Code § 6605, which imposes certain disclosure requirements in connection with Federal research and development awards, provides various enforcement mechanisms for non-compliance. One such mechanism, which the Department of the Army intends to pursue here, is rejection of such applications.

Proposal Title (or grants.gov number):

Acknowledgment of consent:

Covered individual (Signature): Date:

Covered individual (Name print):

Sponsor signature (Signature): Date:

Sponsor signature (Name print):

Institution Name: