Form Approved Through 09/30/2010 OMB No. 0925-0001 |
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Department
of Health and Human Services Grant ApplicationDo not exceed character length restrictions indicated. |
LEAVE BLANK—FOR PHS USE ONLY. |
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Type |
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Number |
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Review Group |
Formerly |
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Council/Board (Month, Year) |
Date Received |
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1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation.)
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2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION NO YES (If “Yes,” state number and title) |
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Number: |
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Title: |
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3. PROGRAM DIRECTOR/PRINCIPAL INVESTIGATOR |
New Investigator No Yes |
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3a. NAME (Last, first, middle) |
3b. DEGREE(S) |
3h. eRA Commons User Name |
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3c. POSITION TITLE
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3d. MAILING ADDRESS (Street, city, state, zip code)
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3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
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3f. MAJOR SUBDIVISION
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3g. TELEPHONE AND FAX (Area code, number and extension) |
E-MAIL ADDRESS: |
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TEL: |
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FAX: |
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4. HUMAN SUBJECTS RESEARCH |
4a. Research Exempt |
If “Yes,” Exemption No. |
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No Yes |
No Yes |
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4b. Federal-Wide Assurance No. |
4c. Clinical Trial |
4d. NIH-defined Phase III Clinical Trial |
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No Yes |
No Yes |
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5. VERTEBRATE ANIMALS No Yes |
5a. Animal Welfare Assurance No. |
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6. DATES OF PROPOSED PERIOD OF SUPPORT (month, day, year—MM/DD/YY) |
7. COSTS REQUESTED FOR INITIAL BUDGET PERIOD |
8. COSTS REQUESTED FOR PROPOSED PERIOD OF SUPPORT |
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From |
Through |
7a. Direct Costs ($) |
7b. Total Costs ($) |
8a. Direct Costs ($) |
8b. Total Costs ($) |
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9. APPLICANT ORGANIZATION |
10. TYPE OF ORGANIZATION |
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Name |
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Public: Federal State Local |
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Address |
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Private: Private Nonprofit |
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For-profit: General Small Business Woman-owned Socially and Economically Disadvantaged |
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11. ENTITY IDENTIFICATION NUMBER
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DUNS NO. |
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Cong. District |
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12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE |
13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION |
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Name |
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Name |
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Title |
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Title |
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Address |
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Address |
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Tel: |
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FAX: |
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Tel: |
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FAX: |
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E-Mail: |
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E-Mail: |
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14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with Public Health Services terms and conditions if a grant is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. |
SIGNATURE OF OFFICIAL NAMED IN 13. (In ink. “Per” signature not acceptable.) |
DATE
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PHS 398 (Rev. 09/07) Face Page Form Page 1
File Type | application/msword |
File Title | PHS 398, fp1 (Rev. 9/07), Face Page, Form Page 1 |
Subject | DHHS, Public Health Service Grant Application |
Author | Office of Extramural Programs |
Last Modified By | curriem |
File Modified | 2007-09-14 |
File Created | 2007-09-14 |