Office of Research and Sponsored Programs, PreAward Services
2 Fairchild Hall, Manhattan, KS 66506-1103
Phone: 785-532-6804; Fax: 785-532-5944; research@ksu.edu
SUBRECIPIENT COMMITMENT FORM
I. Project Information (to be completed by K-State)
(a) K-State PI: ____________________________ (b) Proposal Number: _________________________
(c) Prime Sponsor: ______________________________________________________________________
(d) Proposed Total Project Cost: $______________ (e) Proposed Project Period___________________
(e) Proposal Title: _______________________________________________________________________
II. Subrecipient Information (to be completed by Subrecipient)
(a) Subrecipient Organization: ____________________________________________________________
(b) Subrecipient PI: ______________________________________________________________________
(c) Subrecipient’s DUNS No: _______________ Subrecipient’s EIN: ____________________________
(d) Congressional District of Subrecipient: __________ (e) Congressional District (site): ____________
(f) Registered in SAMS?
Yes
No
Expiration Date: ______________________________
(g) Administrative Contact & Title: _________________________________________________________
Address: ________________________________________________________________________________
E-mail:_________________________________ Phone: _________________________________________
(h) Financial Contact & Title: ______________________________________________________________
Address: ________________________________________________________________________________
E-mail:_________________________________ Phone: _________________________________________
(i) Performance Site/Address: ______________________________________________________________
Phone: _________________________
Fax: ______________________
(j) Legal Address: ________________________________________________________________________
Phone: _________________________
Fax: ______________________
III. Documentation (Subrecipient to provide K-State all documents that are checked)
(a)
Statement of Work (REQUIRED)
(b)
(d)
Budget and Budget Justification, in agency-required format, i.e. R&R Subaward Budget forms
(REQUIRED)
This Subrecipient Commitment Form, completed and signed by the Authorized Organizational
Representative (REQUIRED)
Biographical Sketches of all Key Personnel, in agency-required format
(e)
Other Support (Current and Pending) of all Key Personnel, in agency-required format
(f)
Institutional Letter of Commitment/Support signed by Subrecipient’s AOR
(g)
Other: ________________________________________________________________________
(h)
Other: ________________________________________________________________________
(c)
IV. Certifications (to be completed by Subrecipient)
(a) Conflict of Interest
(1) Not applicable because this project is not being funded by PHS or any other sponsor that has adopted
federal financial disclosure requirements.
(2) Subrecipient hereby certifies that it has an active and enforced conflict of interest policy that is
consistent with the provision of 45 CFR Part 94 and/or 42 CFR Part 50, Subpart F “Responsibility of
Applicants for Promoting Objectivity in Research.” Subrecipient also certifies that, to the best of
Subrecipient’s knowledge, (1) all financial disclosures have been made related to the activities that may
be funded by or through a resulting agreement, and required by its conflict of interest policy; and (2) all
identified conflicts of interest have or will have been satisfactorily managed, reduced or eliminated in
accordance with Subrecipient’s conflict of interest policy prior to the expenditure of any funds under any
resultant agreement.
(3) Subrecipient does not have an active and/or enforced conflict of interest policy and hereby agrees to
abide by K-State’s policy. K-State’s policy is available at:
http://www.k-state.edu/conflict/
(b) Facilities & Administrative (F&A) Rates included in this proposal have been calculated based on:
Our federally-negotiated F&A rates for this type of work, or a reduced F&A rate that we hereby agree to
accept. If this box is checked, a copy of our current F&A rate agreement must accompany this form.
Other rate (Please specify in the Notes/Comments section below the basis on which these rates have
been calculated.)
Not applicable (no Facilities and Administrative requested by Subrecipient)
Notes and Comments:
(c) Fringe Benefit Rates included in this proposal have been calculated based on:
Rates consistent with or lower than our federally-negotiated rates. If this box is checked, a copy of your
benefit rate agreement must accompany this form (or enter URL that links to this information in the
Notes and Comments box.
Other rates (Please specify in the Notes/Comments section below the basis on which these rates have
been calculated.)
Notes and Comments:
(d) Human Subjects (IRB)
Pending
Yes
No
If “yes” Indicate the status of IRB Review:
or Date IRB determined research to be exempt or approved: _______________________
IRB Number: _____________ Federal Wide Assurance (FWA) Number: __________(both must be current)
If “Yes” and NIH funding is involved: Have all key personnel involved completed Human Subjects
Training?
Yes
No
(e) Animal Subjects (IACUC)
Yes
No
Pending or Approval date: ______________ and IACUC #: ________________
Does Subrecipient have a PHS Animal Welfare Assurance #?
Yes
Is your organization/institution AAALAC accredited?
No If “yes” provide AAALAC #:_______
Yes
No If “yes” provide #:_________
(f) Matching/Cost Sharing
Yes
No
Matching/Cost Sharing amounts and justification should be included in the Subrecipient’s budget.
Subrecipient agrees to track all expenditures and report match/cost share to K-State in accordance with the terms of
the subaward agreement.
(g) Export Control
Do you anticipate the use or development of items, software or technology that would require review under Export
Control Laws? If so, please explain:
(h) Responsible Conduct of Research (RCR)
Not applicable because this project is not being funded by NSF, NIH, or USDA
Subrecipient organization/institution certifies that it has a training program in place and will train all
undergraduate and graduate students and postdoc in accordance with applicable RCR requirements.
(i) Fiscal Responsibility
The Subrecipient organization certifies that its financial system is in accordance with generally accepted
accounting principles and:
has the capability to identify in its accounts, all Federal awards received and expended and the Federal
programs under which they were received;
maintains internal controls to assure that it is managing Federal awards in compliance with applicable laws,
regulations and the provision of contract or grants;
complies with applicable laws and regulations;
can prepare appropriate financial statements, including the schedule of expenditures of federal awards;
there are no outstanding audit findings which would impact contract costs. If there are findings, submit a copy
of the most recent report that describes the finding and steps to be taken to correct the finding.
Comments:
V. Approvals of Subrecipient Organization (to be completed by Subrecipient)
By signing this form, I certify that the above information, certifications and representations have been read, are
understood, and are accurate and true to the best of my knowledge. The appropriate programmatic and
administrative personnel involved in this application are aware of pertinent regulations and policies, and are
prepared to establish a subaward agreement with Kansas State University that ensures compliance with such
regulations and policies should this proposal be funded. Subrecipient hereby certifies that neither it nor its
principals nor those who will perform services under a Subaward Agreement awarded pursuant to the proposal
referenced herein are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded by any Federal department or agency from participation in this transaction and have not, within the 3 year
period preceding this application, been convicted of, or had a civil judgment rendered against them or had any
public transaction (Federal, State of Local) terminated for cause or default.
(a) Authorized Organizational Representative
Signature: _________________________________________ Date: ________________________________
Name and Title: ______________________________________________ Phone: _____________________
Address, City, State, Zip: __________________________________________________________________
Email: _____________________________ Research Office URL: _________________________________
Note: Any work begun or expenses incurred prior to execution of a subaward agreement is at the Subrecipient’s
own risk. No work involving human subjects and/or animals may begin until the Subrecipient has obtained
registered Institutional Review Board and/or Animal Care and Use Committee review and approval.