PROPOSAL SUBMISSION FORM (RSP#100.v2)
This form must be completed before a proposal is submitted to an external sponsor.
Click the first space of each field to select, or use the tab-key to move between fields.
Proposal Title:
RSP Proposal#:
Sponsor/Agency Name:
Personnel
Name:
Sponsor RFA/PA #:
Academic Title:
Department/Center:
Mail Stop/Wk phone:
%Credit1
Principal Investigator
Co-PI, Co-Investigator2
Co-PI, Co-Investigator2
Co-Investigator2
Co-Investigator2
1
Must total 100%, TBD by consensus of the investigators and used to represent investigator/dept./college activity on submission/award reports. Used by Grants Accounting to allocate dept./college indirect cost. 2For multiinvestigator proposals, PIs are directed to UT policy 3364-70-22 "PI/PD responsibilities on sponsored projects" and the Research Forms page (see RSP128) at the Research web site (http://www.utoledo.edu/research/) for
guidance on establishing a Multi-PI/PD Leadership plan.
Class: (mark one)
New
Competing-Renewal
Noncompeting-Renewal
Continuation
Supplement
Transfer
Requires: (mark all that apply)
Added Space On/Off Campus3
Space Renovations
Required Equipment Match
UT Tuition Waiver/Fees
3
Space Utilization: Campus Building:
Provide name for each subcontract organization:
Activity Type: (mark all that apply)
Basic-Research
Applied-Research
Clinical-Trial
Equipment/Infrastructure
Education
Fellowship
Service
Involves: (mark all that apply)
Intellectual Property/Tech Transfer
Proprietary information
Multiple Indirect Cost Rates
Work at a Non-UT Institution, not
involving a subcontract
Includes: (mark all that apply)
Faculty Release
Summer Salary
Consultant(s)
Subcontract(s)4
Sponsor-Paid Tuition
Equipment >$25,000 (single item)
Room#:
Off Campus Location:
4
Yes
Regulatory Compliance: (must answer all six)
Office Use Only: Protocol Verification/Database update Complete:
No Human Research Subjects (for advice/to secure approval contact, Biomedical – 419.383.6796, Social/Behavioral – 419.530.2416)
If Yes: - Are all required Institutional Review Board (IRB) oversight protocols approved?
6
No – Protocol approval is pending
Yes – UT-IRB Protocol#(s)5 Signature of Protocol PI(s)
Yes
No Vertebrate Animal Research Subjects (for advice/to secure approval contact – 419.383.4252)
If Yes: - Are all required Institutional Animal Care and Use Committee (IACUC) oversight protocols approved?
6
No – Protocol approval is pending
Yes – UT-IACUC Protocol#(s)5 Signature of Protocol PI(s)
Yes
No Does this work require IRB or IACUC oversight at another institution
If Yes: IRB – Must notify the UT Department of Human Resource Protection ASAP
IACUC – Must provide the UT IACUC with other institution’s IACUC approval letter and OLAW Assurance#
Yes
No Biohazards (Recombinant DNA, Infectious Agents) (for advice/to secure approval contact – 419.383.4252)
If Yes: - Are all required Institutional Biosafety Committee (IBC) oversight protocols approved?
Biosafety Containment Level:
BSL/ABSL/PBSL -1
BSL/ABSL/PBSL-2
BSL/ABSL/PBSL-3
No – Protocol approval is pending
Yes – UT-IBC Protocol#(s) 5 Signature of Protocol PI(s)
Yes
No Subject to U.S. Export Control Laws (for advice contact the Export Control Officer - 419.530.2416)
General Information - http://www.utoledo.edu/research/exportcontrol
Decision Tree - http://www.utoledo.edu/research/exportcontrol/tree.html
Yes
No
5
Select Agents or Toxins – http://www.cdc.gov/od/sap/docs/salist.pdf
Protocol Core# only, leave off prefix/suffix. 6You must confirm with the sponsor’s instructions that application with oversight approval pending is permitted
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Proposal Budget (Must Complete)
Budget requested from Sponsor
Initial Budget Period
Start Date
Office Use Only: Budget Prepared by:
End Date
Direct Costs ($)
F&A Costs($)
Total Budget($)
Cumulative Budget
No
Sources of Cost Share
Cost Sharing
Yes See Below
$ In Kind
Fund Account #
Cash Only
$$ Amount
Cash Only
Budget Period
F&A/Indirects
TOTAL
Project Director(s)/Principal Investigator(s) Certifications
I/We certify by signing below that:
1.
I/We have read and agree to abide by current University policies on conflicts of interest (3364-70-01), patents (3364-70-04), biohazardous materials (3364-70-06), and the
use of human subjects (3364-70-05)/vertebrate animals(3364-70-10) in research, cost-sharing, and other University research policies as appropriate. I/We certify that the
required actions regarding compliance with these policies have been taken.
2.
I/We have read and agree to abide by the University Policy on Integrity in Research and Scholarship and Procedures for Investigating Allegations of Misconduct in Research
and Scholarship (3364-70-21).
3.
I/We will refrain from knowingly conducting activities that may constitute or result in the infringement of any patent, copyright, or other legal right during the project.
4.
I/We agree to provide a complete, accurate and truthful disclosure for this project as required by current UT policy and/or other regulations. I/We agree to disclose
promptly to the Research and Sponsored Programs Office (i) any significant financial interest, as defined in chapter 510 of the National Science Foundation Grant Policy
Manual, that would reasonably appear to be affected by the sponsored research and/or (ii) any significant financial interest in an entity whose financial interest would
reasonably appear to be affected by the sponsored research.
5.
I/We agree to disclose promptly to the Research and Sponsored Programs office and my/our immediate manager, department head, or chair any existing or new situations
in which there is a divergence between my/our private interests and my/our professional obligations to UT or its students.
6.
I/we We acknowledge Article 6.0 of the Collective Bargaining Agreement, the University of Toledo Conflict of Interest policy (3364-70-04) and verify that the proposed
project is in accordance with the applicable provisions of Chapter 102 of the Ohio Revised Code (Public Officers-Ethics), §2921.42 and §2921.43 of the Ohio Revised Code
(Offenses Against Justice and Public Administration) and all other local, state, and federal laws.
7.
The statements contained herein are accurate, complete, and truthful to the best of my/our knowledge and belief.
8.
I/we certify that all proposed experiments, procedures, etc. involving human/animal subjects, recombinant DNA, or biohazards are contained in the regulatory protocols
listed above OR that NO Regulatory Protocol is required. I/we will not seek a spending account until protocol approvals are secured. I/we acknowledge responsibility for
acquiring and maintaining required regulatory compliance oversight for all aspects of the proposed work.
PI/PD ENDORSEMENT
AUTHORIZATION
(Please print name then sign)
(Please print name then sign)
Project Director/Principal Investigator
Co-Director/Co-PI
Co-Director/Co-PI
Co-Director/Co-PI
Co-Director/Co-PI
Date
Date
Date
Date
Date
Department Chair7
Date
Dean (Not required for the Dean of the College of
Medicine)
Date
Department Chair7
Date
Dean(Not required for the Dean of the College of
Medicine)
Date
Department Chair7
Date
Dean(Not required for the Dean of the College of
Medicine)
Date
Department Chair7
Date
Dean(Not required for the Dean of the College of
Medicine)
Date
Department Chair7
Date
Dean(Not required for the Dean of the College of
Medicine)
Date
Vice President for Research
7
Date
Office of UT Innovation Enterprises or VP of
Institutional Advancement
NOTE: Signature is an approval of space/resource allocation, salary arrangements, instructional reassignments and cost-share commitment.
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Date