SUBRECIPIENT CHECKLIST AND CONSORTIUM STATEMENT
OMB Circular A-110, Subpart C, paragraphs 26 and 51(a) require prime recipients of Federal funds to monitor subawards to
ensure subrecipients meet the audit requirements in OMB Circular A-133 and are using funds in accordance with applicable
laws, regulations and terms of the award. Since our subrecipient monitoring responsibilities start at the proposal stage, we
ask for your cooperation in completing this form. Once completed, please print on your institution’s letterhead and return by
fax or scan to:
SPONSOR AGENCY
Research Triangle Institute (RTI International)
PRIMARY RECIPIENT
RTI PRINCIPAL INVESTIGATOR
SUBRECIPIENT INSTITUTION
ADMINISTRATIVE OFFICE ADDRESS
CITY
STATE
ZIP
CONGRESSIONAL
DISTRICT
DUNS #
TIN #
PRE-AWARD ADMINISTRATIVE
CONTACT
EMAIL
POST-AWARD ADMINISTRATIVE
CONTACT
EMAIL
PRINCIPAL INVESTIGATOR
EMAIL
DEPARTMENT
PHONE
PHONE
PHONE
PROJECT TITLE
PERIOD OF PERFORMANCE
to
SUBRECIPIENT COSTS
Using the attached template, please provide
your budget for the full term of the project
including breakout of all F&A and Indirect
costs. Please include a copy of your negotiated
indirect cost rate agreement (NICRA) with your
submission.
INSERT
R&R SUBAWARD BUDGET TEMPLATE
HERE
CERTIFICATIONS
Subrecipient or Subrecipient Principal Investigator Debarred or Suspended
Human Subjects
Revised 2/11/2014
Yes
No
Animal Subjects
Yes
Yes
No
No
Human Stem Cells
Yes
No
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SUBRECIPIENT Financial Conflict of Interest (FCOI) POLICY STATEMENT (choose one response)
(1) I will follow the Conflict of Interest policy established and enforced by: ____________________________
(Subrecipient Organization Name)
By choosing this option, the Authorized Representative’s signature in the Approval box below certifies that its institution’s FCOI
policy complies with the updated PHS Financial Conflict of Interest regulations (Responsibility of Applicants for Promoting
Objectivity in Research for which PHS Funding is Sought, and Responsible Prospective Contractors: 42 C.F.R. Part 50 and
Part 94) and, further, the subrecipient will report identified FCOIs for its investigators to RTI within 30 days of discovery,
allowing RTI sufficient time to report identified FCOIs to the awarding agency.
Skip to Approval box below
(2) I will follow the Conflict of Interest policy established and enforced by RTI International. Names of individuals working on
this project who are responsible for design, conduct, or reporting of the research are shown below. Please visit RTI’s FCOI
website at http://www.rti.org/page.cfm/FCOI_Policy for further details as well as a link to the required Significant Financial
Interest form.
To be completed by RTI
Form 1*
Attached?
Disclosure
(SFI/No SFI)
Date
Subrecipient PI:
Investigator #1:
Investigator #2:
Investigator #3:
COMPANY INFORMATION
Small Business
Classification
(http://www.sba.gov/size/)
Check ALL that apply.
Small Business Concern (SB)
Small Disadvantaged Business or
Minority-owned Business (SB + SDB)*
(Eligibility: Self-certified Minority-owned
business [African American, Asian American,
Native American, or Hispanic American-owned
firms], and/or 8(a) certified.)
Woman-Owned Small Business
(SB+WOSB)*
If not a Small
Business, check one.
Large Corporation
Non-Profit
Veteran-Owned Small Business
(SB+VOSB)*
Service-Disabled Veteran-Owned Small
Business (SB+SDVOSB)*
HUBZone (Historically Underutilized
Business Zone) located firms
(SB+HUBZone)**
Alaska Native Corporation and Indian Tribes
(SB+ANC/IT)*
Foreign/Other
HBCU/MI***
Federal Laws and Regulations provide penalties for vendor misrepresentation of size and status information. The applicable provisions can be
found in 48 C.F.R. 52.219-1 and 15 U.S.C. 645(d).
* 51% or more owned and daily‐managed by the respective Minority‐, Woman‐, Veteran‐individual(s) in accordance with Federal Acquisition
Regulation 52.219‐8
** Valid certification required; HUBZone firms must be listed on http://www.ccr.gov or http://web.sba.gov
*** Historically Black Colleges and University (HBCU) or Minority Institutions (MI)
Do you have a Federally approved Cost Accounting
System (FAR Part 30)?
Yes
No
If Yes, date of last Federal audit:
Do you have a Federally approved Contractor Purchasing
System (FAR Part 44)?
Yes
No
If Yes, date of last Federal audit:
Do you have a Federally approved Government Property
System?
Yes
No
If Yes, date of last Federal audit:
Revised 2/11/2014
Page 2 of 4
What Federal Agency has administrative cognizance over your Federal work?
Agency Name:
ACO Name:
Address:
Phone:
Please provide a copy of your most recent federally approved indirect rate agreement with your cost proposal.
REFERENCES/PAST PERFORMANCE
Yes
No
(If Yes, please provide the RTI Subcontract Number(s)):
Have you subcontracted to RTI before?
Have you performed Federal work before?
Yes
No
Please circle one of the following:
The company identified on this questionnaire (
an award of a contract by any Federal agency.
Is
Is Not ) presently debarred, suspended, or determined ineligible for
The company identified on this questionnaire (
Facilities.
Is
Is Not ) compliant with FAR 52.222-21, Prohibition of Segregated
Evidence of Responsibility
In accordance with the evidence of responsibility criteria of FAR 9.104-1 General Standards, Offeror represents that:
(i)
Offeror has adequate financial resources to perform the contract, or the ability to obtain them in accordance
with FAR 9.104-3(a);
(ii)
Offeror is able to comply with the required or proposed delivery or performance schedule, taking into
consideration all existing commercial and governmental business commitments;
(iii)
Offeror has a satisfactory performance record in accordance with FAR 9.104-3(b) and Subpart 42.15;
(iv)
Offeror has a satisfactory record of integrity and business ethics including satisfactory compliance with the law
including tax laws, labor and employment laws, environmental laws, antitrust laws, and consumer protection
laws;
(v)
Offeror has the necessary organization, experience, accounting and operational controls, and technical skills,
or the ability to obtain them (including, as appropriate, such elements as production control procedures,
property control systems, quality assurance measures, and safety programs applicable to materials to be
produced or services to be performed by the prospective contractor and subcontractors) in accordance with
FAR 9.104-3(a);
(vi)
Offeror has the necessary production, construction, and technical equipment and facilities, or the ability to
obtain them; and
(vii) Offeror is otherwise qualified and eligible to receive an award under applicable laws and regulations.
Revised 2/11/2014
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APPROVAL
The appropriate program and administrative personnel of the institution involved in this application are aware of the sponsor ing
agency’s guidelines and are prepared to establish the necessary inter-institutional agreement(s). The institution makes all
applicable assurances/certifications.
I certify that the information contained in this questionnaire is current, accurate and complete to the best of my knowledge and
belief.
Lastly, I certify that I have read and understand the contents of the RTI Global Supply Chain Supplier Handbook (see
http://rti.org/files/gsc-supplierhandbook.pdf), the RTI Code of Conduct (see http://www.rti.org/pubs/codeofconduct_english.pdf)
and as applicable, my organization is in compliance with the California Transparency in Supply Chains Act of 2010 (see Calif.
Civil Code §1714.43).
Principal Investigator
Authorized Representative Signature
Name:
Title:
Name:
Title:
Date
Date
Revised 2/11/2014
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