PHS 398, fp1 (Rev. xx/09), Face Page, Form Page 1

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Form Approved Through 11/30/2010	OMB No.  0925-0001
Department of Health and Human Services
Public Health Services
Grant Application
Do not exceed character length restrictions indicated.
LEAVE BLANK—FOR PHS USE ONLY.

Type
Activity
Number

Review Group
Formerly

Council/Board (Month, Year)
Date Received
1.	TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation.)
     
2.	RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION    NO  YES 
	(If “Yes,” state number and title)
Number:
     
Title:
     
3.  PROGRAM DIRECTOR/PRINCIPAL INVESTIGATOR
3a.	NAME  (Last, first, middle)
3b.	DEGREE(S)
3h.	 eRA Commons User Name
     
     
     
     
     
3c.	POSITION TITLE
     
3d.	MAILING ADDRESS  (Street, city, state, zip code)
     
3e.	DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
     

3f.	MAJOR SUBDIVISION
     

3g.	TELEPHONE AND FAX  (Area code, number and extension)
E-MAIL ADDRESS: 
TEL:
     
FAX:
     
     
4.	HUMAN SUBJECTS RESEARCH
4a.	Research Exempt   
If “Yes,” Exemption No.
        No    Yes
  No       Yes
     
4b.	Federal-Wide Assurance No.  
4c.	Clinical Trial
4d.	NIH-defined Phase III Clinical Trial
     
  No      Yes
    No      Yes
5.  VERTEBRATE  ANIMALS       No      Yes
5a. Animal Welfare Assurance No.  
     
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
From
Through
7a.	Direct Costs ($)
7b.  Total Costs ($)
8a.  Direct Costs ($)
8b.  Total Costs ($)
     
     
     
     
     
     
9.	APPLICANT ORGANIZATION
10.	TYPE OF ORGANIZATION
Name
     
Public:		  Federal	  State	  Local
Address
     
Private: 		  Private Nonprofit


For-profit:     General         Small Business 
  Woman-owned    Socially and Economically Disadvantaged


11.  ENTITY IDENTIFICATION NUMBER
     


DUNS NO.
     
Cong. District
     
12.	ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE
13.	OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name
     
Name
     
Title
     
Title 
     
Address
     
Address
     
Tel:
     
FAX:
     
Tel:
     
FAX:
     
E-Mail:
     
E-Mail:
     
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

     
PHS 398 (Rev. xx/09)	Face Page	Form Page 1