RFP Page 27 Attach 3 - Proposal Summary and Data Record NIH-2043.doc

DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC HEALTH SERVICE

NATIONAL INSTITUTES OF HEALTH

PROPOSAL SUMMARY AND DATA RECORD

RFP/CONTRACT NUMBER

PROJECT TITLE (Title or RFP or Contract Proposal)

LEGAL NAME AND ADDRESS OF OFFEROR

PLACE OF PERFORMANCE (Full address including ZIP)

TYPE OF CONTRACT PROPOSED

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

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)

DOLLAR VOLUME OF BUSINESS PER ANNUM

THIS OFFER EXPIRES DAYS FROM THE DATE OF THIS OFFER (120 days if not specified)

FOR THE INSTITUTION

TYPED NAME AND TITLE

TYPED NAME AND TITLE

EMPLOYER IDENTIFICATION NUMBER

DATE OF OFFER

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