Attachment 7B - PHS Form 2590

Form Approved Through 9/30/2007
Review Group

Department of Health and Human Services
Public Health Services

Type

OMB No. 0925-0001
Grant Number

Activity

Total Project Period

Grant Progress Report

From:
Requested Budget Period

Through:

From:

Through:

1. TITLE OF PROJECT
2a. PRINCIPAL INVESTIGATOR OR PROGRAM DIRECTOR
(Name and address, street, city, state, zip code)

3. APPLICANT ORGANIZATION
(Name and address, street, city, state, zip code)

2b. E-MAIL ADDRESS

4. ENTITY IDENTIFICATION NUMBER

2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

5. TITLE AND ADDRESS OF ADMINISTRATIVE OFFICIAL

2d. MAJOR SUBDIVISION

E-MAIL:
6. HUMAN SUBJECTS
6a. Research Exempt
No
Yes

No

7. VERTEBRATE ANIMALS
6b. Human Subjects Assurance No.

If Exempt (“Yes” in 6a):
Exemption No.
If Not Exempt (“No” in 6a):
IRB approval date

Yes
6c. NIH-Defined Phase III
Clinical Trial
No

7b. Animal Welfare Assurance No.
Yes

Full IRB or
Expedited Review

8. COSTS REQUESTED FOR NEXT BUDGET PERIOD
8a. DIRECT $

7a. If “Yes,” IACUC approval Date

No

Yes

9. INVENTIONS AND PATENTS
No

8b. TOTAL $

10. PERFORMANCE SITE(S) (Organizations and addresses)

Yes

If “Yes,”

Previously Reported
Not Previously Reported

11a. PRINCIPAL INVESTIGATOR
TEL
OR PROGRAM DIRECTOR (Item 2a)
FAX
11b. ADMINISTRATIVE OFFICIAL
NAME (Item 5)

TEL
FAX

11c. NAME AND TITLE OF OFFICIAL SIGNING FOR APPLICANT
ORGANIZATION (Item 14)
NAME
TITLE
TEL

FAX

E-MAIL
12. Corrections to Page 1 Face Page

13. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the SIGNATURE OF OFFICIAL NAMED IN
statements herein are true, complete and accurate to the best of my knowledge, and accept the 11c. (In ink. “Per” signature not
obligation to comply with Public Health Services terms and conditions if a grant is awarded as a acceptable.)

DATE

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.

PHS 2590 (Rev. 04/06)

Face Page

Form Page 1

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Contact Principal Investigator/Program Director:
2a. PRINCIPAL INVESTIGATOR OR PROGRAM DIRECTOR
(Name and address, street, city, state, zip code)

2b. E-MAIL ADDRESS

2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

2d. MAJOR SUBDIVISION

2e. TELEPHONE AND FAX (Area code, number and extension)
TEL:

FAX:

2a. PRINCIPAL INVESTIGATOR OR PROGRAM DIRECTOR
(Name and address, street, city, state, zip code)

2b. E-MAIL ADDRESS

2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

2d. MAJOR SUBDIVISION

2e. TELEPHONE AND FAX (Area code, number and extension)
TEL:

FAX:

2a. PRINCIPAL INVESTIGATOR OR PROGRAM DIRECTOR
(Name and address, street, city, state, zip code)

2b. E-MAIL ADDRESS

2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

2d. MAJOR SUBDIVISION

2e. TELEPHONE AND FAX (Area code, number and extension)
TEL:

FAX:

2a. PRINCIPAL INVESTIGATOR OR PROGRAM DIRECTOR
(Name and address, street, city, state, zip code)

2b. E-MAIL ADDRESS

2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

2d. MAJOR SUBDIVISION

2e. TELEPHONE AND FAX (Area code, number and extension)
TEL:
PHS 2590 (Rev. 04/06)

FAX:
Face Page-continued

Form Page 1-Continued

Principal Investigator/Program Director (Last, First, Middle):

DETAILED BUDGET FOR NEXT BUDGET FROM
PERIOD – DIRECT COSTS ONLY
PERSONNEL (Applicant organization only)
NAME

ROLE ON PROJECT

THROUGH

Months Devoted to Project
Cal.

Acad.

Summer

Mnths

Mnths

Mnths

GRANT NUMBER

DOLLAR AMOUNT REQUESTED (omit cents)
SALARY
REQUESTED

FRINGE
BENEFITS

TOTALS

0

Principal Investigator

SUBTOTALS
CONSULTANT COSTS

EQUIPMENT (Itemize)

SUPPLIES (Itemize by category)

TRAVEL

PATIENT CARE COSTS

INPATIENT
OUTPATIENT

ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)

SUBTOTAL DIRECT COSTS FOR NEXT BUDGET PERIOD
CONSORTIUM/CONTRACTUAL COSTS

$

DIRECT COSTS
FACILITIES AND ADMINISTRATIVE COSTS

TOTAL DIRECT COSTS FOR NEXT PROJECT PERIOD (Item 8a, Face Page)
PHS 2590 (Rev. 04/06)

Page

$
Form Page 2

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Principal Investigator/Program Director (Last, First, Middle):

GRANT NUMBER

BUDGET JUSTIFICATION

Provide a detailed budget justification for those line items and amounts that represent a significant change from that previously
recommended. Use continuation pages if necessary.

CURRENT BUDGET PERIOD

FROM

THROUGH

Explain any estimated unobligated balance (including prior year carryover) that is greater than 25% of the current year’s total budget.

PHS 2590 (Rev. 09/04, Reissued 4/2006)

Page

Form Page 3

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Principal Investigator/Program Director (Last, First, Middle):

GRANT NUMBER

PROGRESS REPORT SUMMARY
PERIOD COVERED BY THIS REPORT
FROM
THROUGH

PRINCIPAL INVESTIGATOR OR PROGRAM DIRECTOR

APPLICANT ORGANIZATION

TITLE OF PROJECT (Repeat title shown in Item 1 on first page)

A. Human Subjects (Complete Item 6 on the Face Page)
Involvement of Human Subjects

No Change Since Previous Submission

Change

B. Vertebrate Animals (Complete Item 7 on the Face Page)
Use of Vertebrate Animals

No Change Since Previous Submission

Change

C. Select Agent Research

No Change Since Previous Submission

Change

D. Multiple PI Leadership Plan

No Change Since Previous Submission

Change

SEE PHS 2590 INSTRUCTIONS.
WOMEN AND MINORITY INCLUSION: See PHS 398 Instructions. Use Inclusion Enrollment Report Format Page and, if necessary,
Targeted/Planned Enrollment Format Page.

PHS 2590 (Rev. 04/06)

Page

Form Page 5

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Principal Investigator/Program Director (Last, first, middle):
GRANT NUMBER

CHECKLIST
1. PROGRAM INCOME (See instructions.)
All applications must indicate whether program income is anticipated during the period(s) for which grant support is requested. If program income is
anticipated, use the format below to reflect the amount and source(s).
Budget Period

Anticipated Amount

2. ASSURANCES/CERTIFICATIONS (See instructions.)
In signing the application Face Page, the authorized organizational
representative agrees to comply with the following policies, assurances
and/or certifications when applicable. Descriptions of individual
assurances/certifications are provided in Part III of the PHS 398. If
unable to certify compliance, where applicable, provide an explanation
and place it after this page.
• Human Subjects Research • Research Using Human Embryonic Stem
Cells • Research on Transplantation of Human Fetal Tissue • Women
and Minority Inclusion Policy • Inclusion of Children Policy • Vertebrate
Animals
3. FACILITIES AND ADMINSTRATIVE (F&A) COSTS
Indicate the applicant organization’s most recent F&A cost rate
established with the appropriate DHHS Regional Office, or, in the case of
for-profit organizations, the rate established with the appropriate PHS
Agency Cost Advisory Office.

Source(s)

• Debarment and Suspension • Drug-Free Workplace (applicable to
new [Type 1] or revised/resubmission [Type 1] applications only) •
Lobbying • Non-Delinquency on Federal Debt • Research Misconduct
• Civil Rights (Form HHS 441 or HHS 690) • Handicapped Individuals
(Form HHS 641 or HHS 690) • Sex Discrimination (Form HHS 639-A
or HHS 690) • Age Discrimination (Form HHS 680 or HHS 690) •
Recombinant DNA Research, Including Human Gene Transfer
Research • Financial Conflict of Interest (except Phase I SBIR/STTR)
• Prohibited Research • Select Agent Research • PI Assurance
• STTR ONLY: Certification of Research Institution Participation.
F&A costs will not be paid on construction grants, grants to Federal
organizations, grants to individuals, and conference grants. Follow any
additional instructions provided for Research Career Awards,
Institutional National Research Service Awards, Small Business
Innovation Research/Small Business Technology Transfer Grants,
foreign grants, and specialized grant applications.

DHHS Agreement dated:

No Facilities and Administrative Costs Requested.

No DHHS Agreement, but rate established with
CALCULATION*
Entire proposed budget period:

Date

Enter Rate as a decimal (e.g., 0.25 for 25%, 0.495 for 49.5%)
Amount of base $

x Rate applied

0.00%

% = F&A costs $

Add to total direct costs from Form Page 2 and enter new total on Face Page, Item 8b.
*Check appropriate box(es):
Salary and wages base

Modified total direct cost base

Other base (Explain)

Off-site, other special rate, or more than one rate involved (Explain)

Explanation (Attach separate sheet, if necessary.):

PHS 2590 (Rev. 04/06)

Page

Form Page 6

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Principal Investigator/Program Director (Last, First, Middle):
GRANT NUMBER

KEY PERSONNEL REPORT
Place this form at the end of the signed original copy of the application. Do not duplicate.
All Key Personnel for the Current Budget Period (do not include Other Significant Contributors)

Name

PHS 2590 (Rev. 04/06)

Degree(s)

SSN
(last 4
digits)

Page

Role on Project
(e.g. PI, Res. Assoc.)

Date of Birth
(MM/DD/YY)

Months Devoted to Project
Cal

Acad

Summer

Form Page 7

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Principal Investigator/Program Director (Last, first, middle):

NEXT BUDGET PERIOD

FROM

GRANT NUMBER

THROUGH

(Follow instructions carefully)
ITEMIZE DIRECT COSTS REQUESTED FOR NEXT BUDGET PERIOD

DOLLAR AMOUNT REQUESTED (omit cents)

PREDOCTORAL STIPENDS

No. Requested:

$

No. Requested:

$

POSTDOCTORAL STIPENDS (Itemize)

OTHER STIPENDS (Specify)

$
$

TOTAL STIPENDS
TUITION and FEES (including Health Insurance when applicable - see new Instructions) (Itemize)

$
TRAINEE TRAVEL (Describe)

$
TRAINEE RELATED EXPENSES (including Health Insurance when applicable - see new Instructions)

$
TOTAL DIRECT COSTS FOR NEXT BUDGET PERIOD (Also enter on Page 1, Item 8a)
PHS 2590 (Rev. 09/04, Reissued 4/2006)

Page

$
Kirschstein-NRSA Additional Budget Page 2

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Principal Investigator/Program Director (Last, first, middle):
GRANT NUMBER

Summary of Trainees

Complete for trainees who have left the program or who have completed their training (during this reporting
period)
Name

Degree Earned

Current Position

Complete for all trainees for this reporting period.
Distribution of Trainees According to Category: Use the table on the “Inclusion Enrollment Report Format
Page.” See PHS 398.

PHS 2590 (Rev. 09/04, Reissued 4/2006)

Page

Kirschstein-NRSA Summary of Trainees
Additional Form Page 5

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Principal Investigator/Program Director (Last, First, Middle):

Targeted/Planned Enrollment Table
This report format should NOT be used for data collection from study participants.
Study Title:
Total Planned Enrollment:
TARGETED/PLANNED ENROLLMENT: Number of Subjects
Ethnic Category

Females

Sex/Gender
Males

Total

Hispanic or Latino
Not Hispanic or Latino
Ethnic Category: Total of All Subjects *
Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Racial Categories: Total of All Subjects *
* The “Ethnic Category: Total of All Subjects” must be equal to the “Racial Categories: Total of All Subjects.”

PHS 398/2590 (Rev. 09/04, Reissued 4/2006)

Page

Targeted/Planned Enrollment Format Page

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Principal Investigator/Program Director (Last, First, Middle):

Inclusion Enrollment Report
This report format should NOT be used for data collection from study participants.
Study Title:
Total Enrollment:

Protocol Number:

Grant Number:
PART A. TOTAL ENROLLMENT REPORT: Number of Subjects Enrolled to Date (Cumulative)
by Ethnicity and Race
Sex/Gender
Unknown or
Ethnic Category
Females
Males
Not Reported

Total

**

Hispanic or Latino
Not Hispanic or Latino
Unknown (individuals not reporting ethnicity)

*

Ethnic Category: Total of All Subjects*
Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Unknown or Not Reported

*

Racial Categories: Total of All Subjects*

PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics or Latinos Enrolled to Date (Cumulative)
Racial Categories

Females

Males

Unknown or
Not Reported

Total

American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Unknown or Not Reported

**

Racial Categories: Total of Hispanics or Latinos**
* These totals must agree.
** These totals must agree.
PHS 398/2590 (Rev. 09/04, Reissued 4/2006)

Page

Inclusion Enrollment Report Format Page

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