Florida International University
Office of Research & Economic Development
Subcontract/Amendment Request Form
Office of Sponsored Research & Economic Development Subcontracting Group
To:
From:
Re:
Subcontract/Amendment Request
Date: Thursday, March 03, 2016
Note: Please return the completed and signed form, with attachments, to my attention for processing. Appendices must
be typed attachments. Once the subcontract/amendment is complete it will be returned for your review before
forwarding to the subcontractor for execution.
1.
Project ID:
Principal Investigator:
2.
Document type:
New Subcontract
3.
4.
Sponsor:
Amendment to existing subcontract
If this is an amendment request, please explain what in the original subcontract needs to be modified.
Name of the Subcontractor
(University/Organization/etc.)
5.
Period of performance for the
subcontract/amendment
6.
Contact information for
Subcontractor PI
From:
Name:
To:
Title:
Address:
Telephone:
Fax:
Email:
7.
Contact information for
Subcontractor Contract
Administrator
Name:
Title:
Address:
Telephone:
Fax:
Email:
8.
To whom at Subcontractor should
FIU send the completed
subcontract/amendment?
Name:
Title:
Address:
Telephone:
Fax:
Email:
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Office of Research & Economic Development
9.
Statement of work for the subcontractor (please attach typed statement of work as Appendix A and be as complete as
possible)
10.
Budget or deliverable schedule for the subcontractor's work (please attach budget as Appendix B)
11.
Termination notice for the subcontract: 30 or 60 days?
12.
Subcontract above 75K requires a Bid Exemption Certification (online form: http://research.fiu.edu/)
13.
Conflict of Interest: Is there any existing or potential conflict of interest relating to this subcontract and the
research project?
30 days
60 days
Yes
No See the Conflicts of Interest in Research policy, #2370.005, at
http://policies.fiu.edu/files/572.pdf for more information. Note that disclosures are required from all FIU
personnel, whether they are full or part-time employees or volunteers, if such persons have a conflict of
interest as relates to the research project. This includes, but is not limited to, volunteer faculty, adjuncts and
students.
If you answered YES above, the applicable FIU individual must complete the Outside Activity/Conflict of
Interest Report at http://hr.fiu.edu/index.php?name=conflict_of_interest. The disclosure will be reviewed to
determine if the conflict can be managed, reduced or eliminated so that the subcontract may proceed.
14.
IRB, IBC or IACUC Approvals: Will there be any studies carried out by the subcontractor, which involve
human subjects (including surveys or data analysis), animals or recombinant DNA molecules?
No, none apply
Yes, human subjects.
Yes, animal use.
Yes, recombinant DNA.
If any have been checked “yes,” does the attached scope of work accurately reflect what subcontractor will do
in this regard?
Yes
No
Please note that IRB/IACUC/IBC approval from both FIU and the subcontractor are required. The subcontract
and/or amendment will not be executed by FIU until satisfactory documentation is received to meet this
requirement.
15.
Does the sponsor award contain any conditions pertaining to export control s (e.g., foreign national prior
approval, publication limitations) or other confidentiality requirements?
Yes
No
If you answered YES above, list the sponsor award sections that address those requirements:
16.
Does the sponsor award require prior sponsor approval of the subcontractor or the subcontract agreement?
Yes
No
If you answered YES above, list the section of the sponsor award the addresses that:
Attach a copy of the written approval from the sponsor for this subcontract agreement.
17.
Previously Executed Agreements: Is this subcontract related to a previously executed confidentiality of other
agreement with the subcontractor?
Yes
No If yes, please identify which prior agreement:
PI Signature: ___________________________________
Date: ___
_______________
Name (typed):
Phone:
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Office of Research & Economic Development
Email:
FOR ORED USE ONLY
Export Controls:
___________/_______________/____________
Restricted Parties Search (RPS) completed on:
RPS results attached to this memo.
IRB/IACUC/IBC Approvals:
If subcontract SOW involves human subjects, animal use or Recombinant DNA, verify that IRB/IACUC/IBC approval
from BOTH the subcontractor and FIU are in place.
Subcontractor IRB approval No: _____________________ received
FIU IRB approval No: _____________ in place
Subcontractor IACUC approval No: _____________________ received
FIU IACUC approval No: _____________ in place
Subcontractor IBC approval No: _____________________ received
FIU IBC approval No: _____________ in place
ORED Representative Signature: ______________________________ Date: _______________________
Pre-Award:
If subcontract scope of work requires IRB, IACUC and/or IBC approval and such approval(s) from both the
subcontractor and FIU cannot be verified, route to ORI for review of IRB, IACUC and/or IBC requirements.
ORI, please check as applicable:
Appropriate IRB/IACUC/IBC approval is in place for subcontractor’s work. Subcontract may proceed to
execution.
Subcontract may not be executed. IRB/IACUC/IBC has not approved subcontractor’s involvement in the study.
__________________________________________
Signature
Print name
Date
ORI Comments:
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