ROSE-HULMAN INSTITUTE OF TECHNOLOGY
PROPOSAL INFORMATION FORM
GENERAL INFORMATION This form must be completed and provided as the cover page to each grant or contract application
Application to (Sponsor)
Proposal Due Date
Project Director/PI
PI/PD Phone Number
Proposal Title/Subject
TYPE OF APPLICATION:
New
Revision
Amendment
F&A DEPARTMENTAL ALLOCATION
Grant
Contract1
Subcontract
Other Agreement
Internal
Federal
State
Private
Corporation
Foundation
DEPARTMENT
%F&A
TOTAL
100%
1.
2.
3.
4.
Other
Contribution/Exchange
1
Attach Contract Review Sheet
BUDGET INFORMATION
Project Dates
Direct Costs
F&A Costs
Cost-Share Required
Cost-Share Proposed
From:
To:
Please answer the following questions. If answer to question is yes, complete corresponding items on page 2. Attach additional sheets as
necessary to fully answer questions.
Yes
No
1. Is Cost Sharing or Matching Required by the Sponsor or Proposed by RHIT?
2.
3.
4.
5.
6.
7.
8.
Is F&A Cost Recovery projected to be less than the Institute’s current approved rate?
Will this project require a reduction in teaching load?
Will this project require ≥1 mo effort during the AY for which No salary support is requested?
Does this project involve personnel/other resources from RHV or other RHIT departments?
Will a portion of the work be performed by an individual or Institution external to RHIT?
Does this project involve use of radioactive materials, biohazard agents or controlled substances?
Does this project involve the use of animals or human subjects?
9. Do you or any key project personnel have a conflict of interest related to this project as defined in the
RHIT Conflict of Interest Policy?
10. Will this project require additional space, renovations, remodeling, special facilities?
11. Will this project require significant IT hardware or software support from the Institute ?
12. Do you anticipate generating income as a result of this project (see examples p.2) ?
13. Do you anticipate generating new Intellectual Property as a part of this project?
14. Does this project involve an existing RHIT invention (yours or another investigator’s)?
15. Will students be funded by this project?
DEPARTMENTAL REVIEW (Signature indicates recommend proceeding with a formal application)
Principal Investigator
Date
Department Head
Date
Co-Investigator
Date
Department Head
Date
Co-Investigator
Date
Department Head
Date
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1. Estimate amount, sources, and whether cost share is required (R) or proposed (P)
Source of Cost-Sharing
FOAPAL
Amount
Total Cost Share
% of
Total Cost-Share
(R)equired
(P)roposed
RHIT Operating Budget
Existing External Support
Department Budget
Unrecovered Indirect Costs
TOTALS
$
100%
0.00
2. Please indicate F&A Cost Rate and Base for this proposal and reason for using rate other than the RHIT
approved rate:
3. List individuals requiring adjustment in teaching load. Please estimate the total adjustment required (months) and how that
total is projected to be spread over each quarter.
Place No. of Months for each quarter in appropriate column -use the conversion:
one 4-cr course release in a quarter equals 1 month
Name
Total Months
Fall Qtr
Winter Qtr
Spring Qtr
4. Please indicate amount of effort to be expended each Academic Year; explain why sponsor support is not requested; include effort
on current and pending support page
Effort Expended per year:
Explanation:
5. Please list the other departments involved
6. Costs must be budgeted under sub-award category. Subcontractor must provide: Statement of Work, Proposed Budget
and Budget Justification, Biographical Sketches for Sr. Personnel, Current and Pending Support for Senior Personnel,
Description of Facilities, and Face Page or Letter of Intent signed by the Principal Investigator and Institutional Official.
7. Please list radioactive material, biohazards, or controlled substances to be used
8. Protocol No.
Status of Protocol (NS= Not Submitted; P= Pending; A=Approved)
Please attach a brief description of how human subjects or animals are to be used.
9. All key personnel with a conflict or potential conflict of interest related to this project must complete the RHIT Conflict of Interest
Disclosure Form and forward it to the VP for Academic Affairs prior to submission of this proposal. Sponsored Programs will be
notified by the VP for Academic Affairs when a plan for managing the conflict has been completed.
10. Please indicate plans for renovation and/or acquisition of additional space including a quote from VP Facilities for renovation
costs
11. Describe support required (consult IAIT):
12. Please indicate the nature of program income:
Fee or income for services (participant fees)
User fee/rental income of property acquired under grant
Sale of items developed using grant/contract funds.
13. Disclose all inventions via RHIT Disclosure Form (see Dean of the Faculty web page). Additionally, the Sponsor may require
invention reporting. Please also be sure to notify Sponsored Programs should inventions be discovered as a part of this project.
14. Please provide title of invention/inventions:
15. Students will be required to complete on-line RCR ethics training prior to being hired for this award.
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INSTITUTE REVIEW AND APPROVAL
By signing below, each individual certifies his/her comfort with level of Institute commitment and recommends submission of proposal.
Comments:
Director, Sponsored Programs
Matthew D. Davis, Interim VP of Finance
Richard E. Stamper, Interim Dean of Faculty
Date
Date
Date
Phillip Cornwell, VPAA
Date
Ricky McCurry, VPIA
Date
Robert A. Coons, Interim President & CAO
IRPA Assessment Reviewed
Date
Date
Additional Comments:
Copies to:
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