EPCTU RFP Attachment 18 Proposal Summary and Data Record.pdf
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- Attached to
- Early Phase Clinical Trial Units (EPCTU)
- Solicitation number
- RFP-NIAID-NIH-AI-75N93020R00023
About this file
This document is a proposal summary and data record template for a cost-reimbursement, fixed price, or cost-plus-fixed-fee contract with the Department of Health and Human Services National Institutes of Health. It requires information on the project title, RFP number, offeror name and address, place of performance, estimated time and direct costs to complete the project, proposed start date, whether a subcontract is included, principal investigator details, authorization to negotiate and execute contracts, and human subjects research compliance. It will be used to identify, review and manage NIH extramural programs. The proposal expires 120 days from the date of the offer unless otherwise specified.
The related federal contract opportunity is a solicitation for Early Phase Clinical Trial Units. Solicitation number RFP-NIAID-NIH-AI-75N93020R00023 is seeking proposals for the National Institute of Allergy and Infectious Diseases within the Department of Health and Human Services National Institutes of Health. No further details are provided on products, services, response dates or award timing.
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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 .