UNIVERSITY OF SOUTH ALABAMA
SPA Log #
Deadline Date
TRANSMITTAL FORM
SPA Use Only
Receipt
USA Research –Enhancing the present and inventing our tomorrow
Postmark
PROPOSAL DATA
T ITLE :
PROPOSAL ABSTRACT :
PROPOSAL TYPE
PROJECT TYPE
AGREEMENT TYPE
Grant
Research
New
____________________
________________________
INVESTIGATOR DATA
PHONE
PI
PI
PI
PI
PI
PI
PI
PI
P
AGENCY DATA
A GENCY ABBRV /N AME
PROGRAM N AME
FUNDING S OURCE :
CFDA:
Federal
___________________________
ENTIRE PROJECT PERIOD:
FROM
TO
C URRENT B UDGET PERIOD :
FROM
TO
BUDGET DATA
CURRENT B UDGET PERIOD :
ENTIRE PROJECT PERIOD:
D IRECT $
D IRECT $
F&A
$
T OTAL
$
F&A
0
C OST S HARING I TEM
AMOUNT
BANNER ACCOUNT #
$
0
T OTAL $
N/A
F&A RATE : _____________________________________________
I F O THER, L IST R ATE
D OCUMENTATION ATTACHED
D OCUMENTATION ATTACHED
T OTAL:
COMPLIANCE T YPE
I F ANY OF THE FOLLOWING ARE USED IN YOUR RESEARCH, PLEASE CHECK THE APPROPRIATE BOX.
PROTOCOL #
JIT #
Y ES
STUDENT O BLIGATION
COMPLIANCE REVIEWS
A NIMAL USE
B IOLOGICAL MATERIALS
EMBRYONIC S TEM CELLS
H UMAN S UBJECTS
RADIATION S AFETY
SAFETY & E NVIRONMENTAL
SELECT A GENTS OR T OXINS
Office of Sponsored Projects Administration
FY15
Internal University Use Only
0
Yes No
EXPORT CONTROLS
Please contact the Research Compliance & Assurance office should you have any questions on Export Control at 460-6625.
Will any equipment be exported by the University in the course of this project?
Will this project require any export controlled information to be received on campus?
Will this project likely involve any foreign nationals?
INVESTIGATOR D ISCLOSURES AND CERTIFICATIONS
Yes
No
Principal and co-investigators certify that the information submitted in this application is true, complete, and accurate to the best
of their knowledge. The PI agrees to accept responsibility for the scientific conduct of the project and reporting requirements.
The facilities/and other University resources necessary to complete the proposed project will be available to the project.
Documentation attached
INTERDISCIPLINARY INCENTIVE P LAN
Yes
N/A
I elect to have Interdisciplinary Incentive benefit to which I may be entitled, for this proposal, directed:
Included in the PI(s) paycheck as a one-time payment.
Forwarded to the Dean’s office and further allocated for the PI(s) use.
F INANCIAL CONFLICT OF INTEREST CERTIFICATION
Yes No
Do you or your family have any financial interests that could reasonably impact the proposed research or educational activity?
Do you or your family have financial interest in any entity whose financial interest could reasonably impact the proposed research
or educational activity? *Family is defined as spouse, child, grandchild, parent, grandparent, sibling, niece, nephew, aunt, uncle, cousin, in-laws, and step relations in
those capacities, as well as any person living in the household of the Employee.
PHS FCOI
Yes No
If No, >>>
Is this submission to a Public Health Service (PHS) agency or PHS FCOI compliant agency? See attached list
skip A.& B.
B1.& B2.
A. If a PHS Continuation, check No and no form is required. If PHS New, Renewal, Revision, check Yes and attach the
Financial Conflict of Interest Certification Form completed by PI prior to proposal submission.
B. Is there a sub-awardee(s) contained in the above submission to a PHS agency or PHS FCOI compliant agency?
*See attached list. If so, please enter the name(s) of the sub-recipient organization(s).
B.1. Please list below the sub-recipient organization(s) named above that are on the Federal Demonstration Partnership PHS FCOI
Compliant list. A FCOI Sub-recipient Commitment & Disclosure Form is NOT needed.
B.2. Please list below the sub-recipient organization(s) NOT on the Federal Demonstration Partnership PHS FCOI compliant list. A
FCOI Sub-recipient Commitment & Disclosure form MUST be completed by sub-recipient & attached prior to proposal submission.
CERTIFICATION OF EXPENDITURES
Questions about the Certification of Expenditures should be directed to the Office of Grants and Contracts Accounting at 431-1379.
The new federal Uniform Guidance (2014) requires investigators and academic units understand and assure all expenditures levied against an external award are
applicable, accurate, and consistent with the terms of the award. Signatures on the Transmittal Sheet acknowledge this requirement.
“When approving expenditures for a subsequent award the Principal Investigator, Department and College certify to the best of their knowledge and belief that the
expenditures are true, complete, and accurate, and the disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the award.
In addition, regular reviews of fund financial activity will be performed to confirm all posted expenditures are in conformity with Federal, State, University of South
Alabama, and sponsor spending regulations.”
APPROVALS
___________________________________________________
__________________________________________________________
PRINCIPAL I NVESTIGATOR
COLLEGE D EAN
D ATE
D ATE
___________________________________________________
__________________________________________________________
PI/C OPI
COLLEGE D EAN
D ATE
___________________________________________________
PI/C OPI
__________________________________________________________
D ATE
COLLEGE D EAN
___________________________________________________
D EPARTMENT C HAIR
D ATE
D ATE
__________________________________________________________
D ATE
COLLEGE D EAN
D ATE
___________________________________________________
__________________________________________________________
D EPARTMENT CHAIR
Office of Sponsored Projects Administration
D ATE
D ATE
___________________________________________________
__________________________________________________________
D EPARTMENT CHAIR
Authorized Organizational Representative
Office of Sponsored Projects Administration
D ATE
FY15
D ATE
Internal University Use Only
Public Health Service
Financial Conflict of Interest (PHS FCOI) Compliant Federal
Agencies / Organizations
PHS FCOI Federal Agencies
AHRQ
ATSDR
CDC
FDA
HRSA
IHS
NIH
OGA
OASH
ASPR
OMH
SAMHS
Agency for Healthcare Research and Quality
Agency for Toxic Substances and Disease Registry
Centers for Disease Control
Food and Drug Administration
Health Resources and Services Administration
Indian Health Services
National Institutes of Health
Office of Global Affairs
Office of the Assistant Secretary for Health
Office of the Assistant Secretary for Preparedness and Response
Office of Minority Health
Substance Abuse and Mental Health Services Administration
NON-PHS FCOI Organizations
ACS
AHA
ALA
ARF
JDRF
LA
LFA
SKBCF
American Cancer Society
American Heart Association
American Lung Association
Arthritis Foundation
Juvenile Diabetes Research Foundation
Lupus Alliance
Lupus Foundation of America
Susan G. Komen Breast Cancer Foundation