California State University, Fullerton
Sponsored Project Internal Routing Form
Project #
check if this is an HPRI proposal
1. Investigator(s) Information (List all CSUF key personnel involved in the project & specify the semester or semesters in which the time
requested will be provided (i.e. Spring 05), the type of time requested, and the percentage of time or the number of units of released/reassigned time
being requested). Please complete page 4 for additional key personnel.
Note to investigators/key personnel:

For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form (FCOI). For proposals to non-profits & other nonexempt entities please complete the Form 700-U. Please see footnote (page 3) on Conflict of Interest1 .


Total faculty overload time for any given academic year is 25% maximum.
Certification: Each Faculty/Staff member certifies that 1) They agree to be bound by the terms and conditions of the external grant or contract
which supports this proposed activity; 2) They agree to abide by the University’s research policies, including UPS 630.000 (scientific
misconduct), UPS 620.000 (human participants), UPS 610.000 (conflict of interest) and UPS 100.005 (patents); 3) Their time commitments for
this and other externally funded projects do not exceed 125% of my time during the academic year per CSU Policy, HR 2002-05, dated
February 19, 2002; 4) They certify that they are aware of the federal regulations regarding Lobbying and Drug-Free Workplace and will comply
as necessary; 5) They have provided prior knowledge to their Chair and Dean about their intent to prepare this proposal. 6) By signing off in
Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not
delinquent in repaying debts to the federal government.
Principal Investigator (last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Non-Academic–
%
Cost Match: Release Time
%
Cost Match: Non-Academic:
Overload Time –
%
No Salary Charge
%
For NSF Science and Engineering Research or Education Proposals: By signing off in Cayuse, you certify that in accordance with Section 7009 of the America Creating
Opportunities to Meaningfully Promote Excellence in Technology, Education, and Science (COMPETES) Act (42 U.S.C. 18620-1), effective January 4, 2010, that at the time of
proposal submission to NSF, I will have a plan to provide appropriate training and oversight in the responsible and ethical conduct of research to undergraduates, graduate
students, and postdoctoral researchers who will be supported by NSF to conduct research. I acknowledge that while training plans are not required to be included in the
submitted proposal that such plans will be subject to review upon request.
Click to choose
Role
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Cost Match: Release Time
%
Non-Academic–
%
Cost Match: Non-Academic:
Overload Time –
%
No Salary Charge
%
No Salary Charge
%
No Salary Charge
%
Click to choose
Role
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Cost Match: Release Time
%
Click to choose
Role
Non-Academic–
%
Cost Match: Non-Academic:
Overload Time –
%
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Cost Match: Release Time
%
Non-Academic–
%
Cost Match: Non-Academic:
2. Sponsor
Name:
Overload Time –
%
Sponsor Institute/Division:
Program Name:
Funding Opportunity #:
CFDA# (if applicable):
3. Project
Title:
4. Funding Source:
5. Type of Proposal:
Federal
Federal Flow-Through
State of CA
CA State Flow-Through
Business/For Profit
Non-Profit/Private Foundation
Private-Individual
Private-Alumni
Foreign Source
Local (includes other states, cities,
county, community colleges & public school districts)
7. Kind of Application: Indicate the type of proposal or
project that is being submitted for review.
FY2015-16
Grant
Cooperative Agreement
Subcontract (Prime
Contract: Fixed Price
Cost Reimbursement
OTHER
6. Special Funding:
ARRA
)
Congressionally Directed
Other
8. Project Type: (select only ONE)
1
Pre-Proposal
Letter of Intent
New Proposal/New Contract
Revision
Supplement
Continuation/Renewal
Postmark Date:
Original OGC
Project
Number:
9. Sponsor
Deadline:
10.
Basic Research
Applied Research
Research Development
Public Service
Scholarships and Fellowships
Curriculum Development/Instruction
Student Services/Support
Equipment
Construction
Training
Receipt Date:
Electronic Submission Date/Time:
Rate Applied:
IDC Base:
Target Date:
%
(specify MTDC, TDC, etc)
Location of Project
ON campus
Location (if off campus):
OFF campus
11. Brief Description of Project: (Please provide a 2-3 sentence description)
12. Total Funds
Requested:
13. Proposed Project Period: (mo/da/year)
$
$
$
Direct Costs:
F&A (Indirect) Costs:
Total Costs:
Start Date:
End Date:
14. Cost Sharing 2:
Cost Share Sources 3
Total
Required per sponsor guidelines?
Yes
No
(enter source of funds below)
If Yes, % or $ req.:
CSUF Cost Share (
in-kind /
Third Party Cost Share (
cash):
in-kind /
cash):
$
CSUF:
$
Third Party:
$
Total Cost Share:
15. Additional Budget Information & Resources (Please indicate whether this project involves any of the following):
Equipment Purchases (≥$5,000/system)
Est. Costs (if applicable): $
Source:
Additional or Renovated Space
Est. Costs (if applicable): $
Source:
Special Facilities
Est. Costs (if applicable): $
Source:
Special Insurance Requirements
Est. Costs (if applicable): $
Source:
Other
Est. Costs (if applicable): $
Source:
16. Intellectual Property
Potential Copyright
Potential Invention
Other
(Check if applicable):
Potentially Patentable Process or Idea
Trademark
17. Verification of Compliance:
Committee
Status
Approvals/Protocols
N/A
Not yet
submitted
Pending
Approved (Enter Date and Protocol #)
Animal Subjects
Human Participants
Health & Safety, Chemical/
Radioactive Materials,
Radioisotopes
Bio-hazardous Materials,
pyrophoric, shock/friction
sensitive chemicals
If applicable, please contact EHIS at
http://ehis.fullerton.edu/ContactUs.asp
If applicable, please contact EHIS at
http://ehis.fullerton.edu/ContactUs.asp
18. Involvement of Students
Mark all that apply:
Does this project involve student hiring?
Yes
If Yes:
Number of Undergraduate Students
Number of Graduate Students
FY2015-16
No
Unpaid participation of CSUF students?
Yes
If Yes:
Number of Undergraduate Students
No
Number of Graduate Students
2
Please mark the appropriate description of student activity: (Mark all that apply)
Teaching/Tutoring
Advising/Mentoring of Others
Internship
Technical (i.e., Web development)
Research/Laboratory Work
Course Credit
Field Work
Clerical/Administrative
Training
Community Engagement
19. Involvement of Post doc(s)
Does this project involve hiring of post doc(s)?
Yes
No
If Yes, please list the names of post doc, if available, or mark TBH (to be hired).
Name:
% Effort:
Name:
% Effort:
Name:
% Effort:
FY2015-16
3
20. Risk Management Review Items (check any of the following):
In accordance with Executive Order 890, Administration of Grants and Contracts in Support of Sponsored Programs, please carefully
review and respond to each specified item detailed in the listing of Risk Management Review Items.
Yes
No
Does the project require/ involve
Yes
No
Does the project require/ involve
Consultants, collaborators, partners
DHHS/FDA/DEA/USDA regulated materials
Subcontract(s)
International travel (specify country):
Recombinant DNA
Modification of any University property or the
installation of equipment
Liquor liability
Auto liability
Microbial agents
Professional liability
Known carcinogen(s)
Skin or scuba diving
Compressed air or gas cylinders
Production of medical waste
Handling of human blood, bodily fluids, or
other potentially infectious materials
Sponsor demanding pre-approval rights over
publications
Radioisotope or lasers
An inherently dangerous activity
Pyrophoric chemicals
Non-University real property
Possible pollution exposure
Operation at a medically-related clinic or facility
Working with comprehensively embargoed
countries (OFAC & EAR): Iran, Cuba, Syria;
and/or countries listed under OFAC or EAR
Targeted Sanctions and Territories - Libya,
Lebanon, Somalia, Belarus, Sudan, North
Korea, Iraq, Yemen, Myanmar (formerly
Burma), Liberia, Zimbabwe, Balkans, the Cote
D'Ivoire (formerly Ivory Coast); and/or ITAR
prohibited countries: Afghanistan, Belarus,
Central African Republic, Cuba, Cyprus,
Eritrea, Fiji, Iran, Iraq, Cote d'Ivoire, Lebanon,
Libya, North Korea, Syria, Vietnam, Myanmar,
China, Haiti, Liberia, Rwanda, Somalia, Sri
Lanka, Republic of the Sudan (Northern
Sudan), Yemen, Zimbabwe, Venezuela,
Democratic Republic of the Congo.
Specify country:
Collaborating with colleagues in foreign
countries? Specify country:
Training foreign nationals in using equipment?
If yes, please specify nationality & equipment:
Shock/friction sensitive chemicals
Minors
Shipping equipment, chemicals,
radioisotopes or biological agents, plants
or soils to or from a foreign country. If Yes,
please specify item and country:
Handling of export-controlled materials
and/or information
Pre-approval of participation of foreign
national students
21. Award Administration or Stewardship (For Office Use Only):
Award to be administered by the CSUF Auxiliary Services Corporation (ASC)
Award to be administered by the Cal State Fullerton Philanthropic Foundation (CSFPF)
Award to be administered by CSU Fullerton (STATE)
1
2
For proposals to NSF or PHS (e.g., NIH) PIs/co-PIs must complete the Financial Conflict of Interest (FCOI) Form. For more information on PHS/NSF Conflict of Interest
definitions please see http://www.fullerton.edu/research/contact-us/Policies.asp. PIs requesting funding from non-profits and other non-public organizations must file a
California Form 700-U form (see CA Fair Practices Commission website at http://www.fppc.ca.gov/index.php?id=500). Details of the Conflict of Interest policy at Cal State
Fullerton can be found at http://www.fullerton.edu/research/ogc/forms-templates.
The OGC recommends that only the minimum amount of cost sharing sponsor required be reflected in the proposal budget. Voluntary, committed, cost-share is discouraged.
Non-reportable university cost match should be appropriately identified as “internal cost-share only.”
FY2015-16
4
3
If the source of cost-share is the CSUF, commitment should be made by the person authorized to approve expenditures against the CSUF account. If cost-share is from a Third
Party, a written commitment from that party is needed prior to proposal submission.
Additional Investigator(s) Information (List all CSUF key personnel involved in the project & specify the semester or semesters in
which the time requested will be provided (i.e. Spring 05), the type of time requested, and the percentage of time or the number of units of
released/reassigned time being requested). Please complete page 4 for additional key personnel.
Note to investigators/key personnel:

For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form (FCOI). For proposals to non-profits & other nonexempt entities please complete the Form 700-U. Please see footnote (page 3) on Conflict of Interest1 .


Total faculty overload time for any given academic year is 25% maximum.
Certification: Each Faculty/Staff member certifies that 1) They agree to be bound by the terms and conditions of the external grant or contract
which supports this proposed activity; 2) They agree to abide by the University’s research policies, including UPS 630.000 (scientific
misconduct), UPS 620.000 (human participants), UPS 610.000 (conflict of interest) and UPS 100.005 (patents); 3) Their time commitments for
this and other externally funded projects do not exceed 125% of my time during the academic year per CSU Policy, HR 2002-05, dated
February 19, 2002; 4) They certify that they are aware of the federal regulations regarding Lobbying and Drug-Free Workplace and will comply
as necessary; 5) They have provided prior knowledge to their Chair and Dean about their intent to prepare this proposal. 6) By signing off in
Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not
delinquent in repaying debts to the federal government.
Note: Total faculty overload time for any given academic year is 25% maximum.
Certification: Each Faculty/Staff member certifies that 1) They agree to be bound by the terms and conditions of the external grant or contract which
supports this proposed activity; 2) They agree to abide by the University’s research policies, including UPS 420.106 (scientific misconduct), UPS 420.103
(human participants), UPS 610.000 (conflict of interest) and UPS 100.005 (patents); 3) Their time commitments for this and other externally funded
projects do not exceed 125% of my time during the academic year per CSU Policy, HR 2002-05, dated February 19, 2002; 4) They certify that they are
aware of the federal regulations regarding Lobbying and Drug-Free Workplace and will comply as necessary; 5) They have provided prior knowledge to
their Chair and Dean about their intent to prepare this proposal.
Click to choose
Role
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Non-Academic–
%
%
Cost Match: Non-Academic:
Overload Time –
%
No Salary
Charge
Cost Match: Release Time
%
Certification: By signing off in Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not
delinquent in repaying debts to the federal government.
Conflict of Interest1: For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form. For proposals to non-profits & other non-exempt entities
please complete the Form 700-U. PLEASE SEE PAGE 3 OF THIS FORM.
Click to choose
Role
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Non-Academic–
%
%
Cost Match: Non-Academic:
Overload Time –
%
No Salary
Charge
Cost Match: Release Time
%
Certification: By signing off in Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not
delinquent in repaying debts to the federal government.
Conflict of Interest1: For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form. For proposals to non-profits & other non-exempt
entities please complete the Form 700-U. PLEASE SEE PAGE 3 OF THIS FORM.
Click to choose
Role
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Non-Academic–
%
%
Cost Match: Non-Academic:
Overload Time –
%
No Salary
Charge
Cost Match: Release Time
%
Certification: By signing off in Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not
delinquent in repaying debts to the federal government.
Conflict of Interest1: For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form. For proposals to non-profits & other non-exempt
entities please complete the Form 700-U. PLEASE SEE PAGE 3 OF THIS FORM.
Click to choose
Role
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Non-Academic–
%
%
Cost Match: Non-Academic:
Overload Time –
%
No Salary
Charge
Cost Match: Release Time
%
Certification: By signing off in Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not
delinquent in repaying debts to the federal government.
Conflict of Interest1: For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form. For proposals to non-profits & other non-exempt
FY2015-16
5
entities please complete the Form 700-U. PLEASE SEE PAGE 3 OF THIS FORM.
Click to choose
Role
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Non-Academic–
%
%
Cost Match: Non-Academic:
Overload Time –
%
No Salary
Charge
Cost Match: Release Time
%
Certification: By signing off in Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not
delinquent in repaying debts to the federal government.
Conflict of Interest1: For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form. For proposals to non-profits & other non-exempt
entities please complete the Form 700-U. PLEASE SEE PAGE 3 OF THIS FORM.
Click to choose
Role
(last name, first name)
Please identify total time below, including any cost-match of effort.
Released/Reassigned Time –
%
Non-Academic–
%
%
Cost Match: Non-Academic:
Overload Time –
%
No Salary
Charge
Cost Match: Release Time
%
Certification: By signing off in Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not
delinquent in repaying debts to the federal government.
Conflict of Interest1: For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form. For proposals to non-profits & other non-exempt
entities please complete the Form 700-U. PLEASE SEE PAGE 3 OF THIS FORM.
FY2015-16
6