Subrecipient Legal Name:
Subrecipient PI Name:
Subrecipient PI E-mail:
Address where research will be performed:
Proposal Title:
Performance Period Begin
Date:
School of Medicine
Research Administration
SUBRECIPIENT COMMITMENT FORM
Phone:
City:
End Date:
Fax:
State:
JHU PI Name:
Prime Sponsor:
DUNS+4 Number:
Registered in CCR: Yes No
SECTION A – Proposal Documents
The following documents are included in our proposal submission and covered by the certifications below (check as applicable):
STATEMENT OF WORK (required) which includes:

Deliverables (tangible and/or non-tangible)

Specific work to be performed
BUDGET AND BUDGET JUSTIFICATION (required)
Biosketches of all Key Personnel, in agency-required format
Other:
SECTION B - Certifications
1. Human Subjects Yes No Approval Date:
If "Yes": Copies of the IRB approval and approved "Informed Consent" form must be provided before any subaward will be issued. Please forward these documents to JHU ’s PI and JHU’s Office of Research Administration as soon as they become available. In accordance with JHU policy, JHU
’s IRB must conduct a secondary review of the subaward work and issue a companion approval before any subaward will be issued.
If "Yes": Have all key personnel involved completed Human Subjects Training? Yes No
2. Animal Subjects Yes No Approval Date:
If "Yes": A copy of the IACUC approval must be provided before any subaward will be issued. Please forward this document to JHU
’s PI and JHU’s Office of Research Administration as soon as it becomes available. In accordance with JHU policy,
JHU’s IACUC must conduct a secondary review of the subaward work and issue a companion approval before any subaward will be issued.
3. Debarment and Suspension
Is the PI or any other employee or student participating in this project debarred, suspended or otherwise excluded from or ineligible for participation in federal assistance programs or activities? Yes No
( if
“Yes”,
explain in Section D Comments below)
The Subrecipient certifies they: (answer all questions below)
are are not presently debarred, suspended, proposed for debarment, or declared ineligible for federal contracts
are are not presently indicted for, or otherwise criminally or civilly charged by a government entity
have have not within three (3) years preceding this offer, been convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) contract of subcontract; violation of Federal or
State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements or receiving stolen property
have have not within three (3) years preceding this offer, had one or more contracts terminated for default by any federal agency
(rev August 22, 2012)

School of Medicine
Research Administration
SUBRECIPIENT COMMITMENT FORM
4. Potential Financial Conflict of Interest (applicable to PHS (includes NIH, NSF, etc.) or other sponsors that have adopted the federal financial disclosure requirements)
Not applicable because this project is not being funded by PHS (includes NIH, NSF, etc.) or other sponsor that has adopted the federal financial disclosure requirements
Applicable – please fill out the attached SFI form.
SECTION C - Audit Status
5. Audit Status
Subrecipient receives an annual audit in accordance with OMB Circular A-133.
Most recent fiscal year completed: FY
Were any audit findings reported? (If "Yes," explain below in Section D Comments) Yes No
Subrecipient DOES NOT receive an annual audit in accordance with OMB Circular A-133.
Subrecipient is a: Non-profit entity (under federal funding threshold)
Foreign entity
For profit entity
Government entity
SECTION D - Budget
Year 1 Direct Costs: _________________________________ Year 1 Total Costs: ______________________________________
Entire Project Direct Costs: ____________________________ Entire Project Total Costs: ________________________________
F&A Rate: ____________
APPROVED FOR SUBRECIPIENT
The information, certifications and representations above have been read, signed and made by an authorized official of the
Subrecipient named herein. The appropriate programmatic and administrative personnel involved in this application are aware of agency policy in regard to subawards and are prepared to establish the necessary inter-institutional agreements consistent with those policies. Any work begun and/or expenses incurred prior to execution of a subaward agreement are at the
Subrecipient’s own risk.
Signature of Subrecipient’s Authorized Official
Name and Title of Authorized Official
Email
Phone
Date
(rev August 22, 2012)
Legal Name of Subrecipient’s Organization/Institution
Address
City, State, Zip
Subrecipient’s Congressional District

School of Medicine
Research Administration
SUBRECIPIENT COMMITMENT FORM
Significant Financial Interest Statement for JHU SOM Subrecipients conducting PHS-Funded Research
Grantor Name
Prime Grant Number
Study Title
Budget Period
JHU Principal Investigator
Subrecipient Name
Subrecipient Principal
Investigator
Under 42 C.F.R. Part 50, Subpart F, institutions carrying out PHS-funded research must maintain an up-to-date, written, enforced policy on financial conflict of interest. In addition, if an institution carries out such research through a subrecipient ( e.g.
, subcontractor or consortium member), the institution must take reasonable steps to ensure that any subrecipient investigator complies with the regulation. The institution must either require that subrecipient investigators comply with the institutional policy or the subrecipient must certify that its policy complies with the regulation.
This form must be completed by all subrecipients of PHS-funded research before any sub-agreements/subcontracts are finalized. The form must be completed by the subrecipient’s designated institutional official. (Note: Questions about this form should be directed to the Office of Policy Coordination by telephone at 410-516-4732 or by email at policy@jhmi.edu
.)
1) Does the subrecipient certify that it maintains an up-to-date, written, enforced policy on financial conflict of interest pursuant to 42 C.F.R. 50.604(a)? (Answer “yes” if the subrecipient has registered with the FDP Institutional Clearinghouse as an institution that is in compliance with these regulations.)
Yes. Subrecipient agrees to submit a Subrecipient FCOI Report to JHU SOM for any investigator determined to have a financial conflict of interest with the Subrecipient’s work for JHU. (See separate form titled “Subrecipient FCOI Report.”)
(Proceed to signatures in Question #32.)
No. (Go to Question #2.)
2) Subrecipient certifies that it will abide by the JHU School of Medicine (SOM) Disclosure and Professional Commitment
Policy (sections A, B(1), C and E) and the JHU Policy on Individual Financial Interests and Financial Conflicts of Interest in
Research. In accordance with these policies, subrecipient certifies that it will report to JHU SOM any identified significant financial interests of subrecipient investigators that are directly related to the subrecipient’s work for JHU. If the JHU SOM determines th at a subrecipient investigator’s significant financial interest constitutes a financial conflict of interest, subrecipient will comply with JHU SOM’s management plan to ensure the conflict is managed.
An investigator means the project director or principal investigator and any other person, regardless of title or position, who is responsible for the design, conduct, or reporting of research funded by PHS, or proposed for such funding, which may include, for example, collaborators or consultants. This definition includes all study team members on PHS-funded IRB applications. This definition is independent of whether one is appointed by or employed by the subrecipient institution.
Investigators also include the following:

Faculty members, if the subrecipient is an academic institution

Any individual who receives any percent of effort under a PHS sub-award

Graduate students at sub-recipient institutions who participate in PHS-supported research or

Any individual who is responsible for the design, conduct, or reporting of PHS-supported research and exercises enough independence to influence the outcome of said research
The final determination regarding who is considered an investigator in PHS-supported research should be made by the PI of the project.
A subrecipient investigator’s significant financial interest means any payment to the investigator and/or an investigator’s financial interest or fiduciary role that is directly related to the subrecipient’s work for JHU . This includes, but is not limited to, the following:
(rev August 22, 2012)

School of Medicine
Research Administration
SUBRECIPIENT COMMITMENT FORM

Income for services (e.g., consulting fees or honoraria) that exceeds $5,000 per year
 Equity interests (e.g., stock, stock options or other ownership interests) with a fair market value greater than $5,000, but not including equity interests in mutual funds
 Intellectual property rights and interests (e.g. receipt of royalty payments), upon receipt of income related to such rights and interests
 Fiduciary role (e.g., Board of Directors member, officer, or manager)

A significant financial interest does not include payments to the investigator by the sub-recipient institution, provided that the institution employs the investigator
None of the investigators or their spouses, domestic partners or dependent children has a significant financial interest that is directly related to the Subrecipient’s work for JHU.
One of more of the investigators, their spouses, domestic partners or dependent children has a significant financial interest that is directly related to the subrecipient’s work for JHU.
Name(s) and email(s) of investigator(s) who have a significant financial interest:
First (Given) Name Last (Family) Name Email Address
Subrecipient warrants that it will comply with requests from JHU SOM for additional information and that it will take all steps identified by JHU SOM as necessary in order for JHU SOM to determine if the significant financial interest(s) constitutes a financial conflict of interest(s) under the regulation. Further, subrecipient agrees that each investigator listed above will disclose his/her significant financial interest that is directly related to the subrecipient’s work for JHU in accordance with the
JHU SOM Disclosure and Professional Commitment Policy. (Questions regarding the disclosure process should be directed to the Office of Policy Coordination at 410-516-5560 or policy@jhmi.edu
.)
3) Subrecipient certifies to the best of its knowledge that at the time of signature the statements on this document are true, as evidenced by the following signatures:
Name of Subrecipient
Designated Institutional Official
Name of Subrecipient
Principal Investigator
Name of JHU
Principal Investigator
Signature
Signature
Signature
Date
Date
Date
(rev August 22, 2012)