5 Checklist

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

     

CHECKLIST

TYPE OF APPLICATION (Check all that apply.)

NEW application. (This application is being submitted to the PHS for the first time.)

RESUBMISSION of application number:

     

(This application replaces a prior unfunded version of a new, renewal, or revision application.)

RENEWAL of grant number:

     

(This application is to extend a funded grant beyond its current project period.)

REVISION to grant number:

     

(This application is for additional funds to supplement a currently funded grant.)

CHANGE of program director/principal investigator.

Name of former program director/principal investigator:

     

CHANGE of Grantee Institution. Name of former institution:

     

FOREIGN application

Domestic Grant with foreign involvement

List Country(ies) Involved:

     

INVENTIONS AND PATENTS (Renewal appl. only) No Yes

If “Yes,”

Previously reported Not previously reported

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

Budget Period

Anticipated Amount

Source(s)

     

     

     

     

     

     

2. ASSURANCES/CERTIFICATIONS (See instructions.) In signing the application Face Page, the authorized organizational representative agrees to comply with the policies, assurances and/or certifications listed in the application instructions when applicable. Descriptions of individual assurances/certifications are provided in Part III and listed in Part I, 4.1 under Item 14. If unable to certify compliance, where applicable, provide an explanation and place it after this page.

3. FACILITIES AND ADMINSTRATIVE COSTS (F&A)/ INDIRECT COSTS. See specific instructions.

DHHS Agreement dated:

     

No Facilities And Administrative Costs Requested.

DHHS Agreement being negotiated with

     

Regional Office.

No DHHS Agreement, but rate established with

     

Date

     

CALCULATION* (The entire grant application, including the Checklist, will be reproduced and provided to peer reviewers as confidential information.)

a. Initial budget period:

Amount of base $

     

x Rate applied

     

% = F&A costs $

     

b. 02 year

Amount of base $

     

x Rate applied

     

% = F&A costs $

     

c. 03 year

Amount of base $

     

x Rate applied

     

% = F&A costs $

     

d. 04 year

Amount of base $

     

x Rate applied

     

% = F&A costs $

     

e. 05 year

Amount of base $

     

x Rate applied

     

% = F&A costs $

     

TOTAL F&A Costs $

     

*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.):

     

4. DISCLOSURE PERMISSION STATEMENT: If this application does not result in an award, is the Government permitted to disclose the title of your proposed project, and the name, address, telephone number and e-mail address of the official signing for the applicant organization, to organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment)? Yes No

PHS 398 (Rev. 09/07) Page     Checklist Form Page