FINAL_Attachment-10-Proposal_Summary_NIH2043.pdf

DEPARTMENT OF HEALTH AND HUMAN SERVICES RFP/CONTRACT NUMBER

PUBLIC HEALTH SERVICE

NATIONAL INSTITUTES OF HEALTH

PROPOSAL SUMMARY AND DATA RECORD

PROJECT TITLE

LEGAL NAME AND ADDRESS OF OFFEROR PLACE OF PERFORMANCE (Full address including ZIP)

COST REIMBURSEMENT FIXED PRICE COST-PLUS-FIXED-FEE OTHER

ESTIMATED TIME REQUIRED TO COMPLETE PROJECT

ESTIMATED DIRECT COSTS IN PROPOSED YEAR (From budget) PROPOSED STARTING DATE

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-INVESTIGATORS (Use attachment if necessary). SOCIAL SECURITY NO. EST. HOURS WEEKLY AREA CODE/TEL. NO.

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 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

June 1982 searsky Typewritten Text Proposal Summary and Data Record, NIH-2043 Attachment 10