Form 1 PHS 398 Paper Application Forms

PHS Applications and Pre-award Related Reporting (OD)

Attachment 3 PHS 398 Paper Application Forms

PHS 398 Paper

OMB: 0925-0001

Document [docx]
Download: docx | pdf

Form Approved Through 10/31/2018 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. 03/16) Face Page Form Page 1

Use only if preparing an application with Multiple PDs/PIs. See http://grants.nih.gov/grants/multi_pi/index.htm for details.

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


3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

3a. NAME (Last, first, middle)

3b. DEGREE(S)

3h. NIH 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:

     

     



3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

3a. NAME (Last, first, middle)

3b. DEGREE(S)

3h. NIH 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:

     

     



3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

3a. NAME (Last, first, middle)

3b. DEGREE(S)

3h. NIH 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:

     

     



3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

3a. NAME (Last, first, middle)

3b. DEGREE(S)

3h. NIH 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:

     

     

PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001 Face Page-continued Form Page 1-continued

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

     


PROJECT SUMMARY (See instructions):

     

RELEVANCE (See instructions):

     

PROJECT/PERFORMANCE SITE(S) (if additional space is needed, use Project/Performance Site Format Page)

Project/Performance Site Primary Location

Organizational Name:

     

DUNS:

     

Street 1:

     

Street 2:

     

City:

     

County:

     

State:

     

Province:

     

Country:

     

Zip/Postal Code:

     

Project/Performance Site Congressional Districts:

     


Additional Project/Performance Site Location

Organizational Name:

     

DUNS:

     

Street 1:

     

Street 2:

     

City:

     

County:

     

State:

     

Province:

     

Country:

     

Zip/Postal Code:

     

Project/Performance Site Congressional Districts:

     

PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001 Page 2 Form Page 2

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

     


SENIOR/KEY PERSONNEL. See instructions. Use continuation pages as needed to provide the required information in the format shown below.

Start with Program Director(s)/Principal Investigator(s). List all other senior/key personnel in alphabetical order, last name first.

Name

eRA Commons User Name

Organization

Role on Project


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


OTHER SIGNIFICANT CONTRIBUTORS

Name

Organization

Role on Project

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Human Embryonic Stem Cells

No

Yes

If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list: http://stemcells.nih.gov/research/registry/eligibilityCriteria.asp. Use continuation pages as needed.

If a specific line cannot be referenced at this time, include a statement that one from the Registry will be used.

Cell Line

     

     

     

     

     

     

     


PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001
Page 3 Form Page 2-continued

Number the following pages consecutively throughout
the application. Do not use suffixes such as 4a, 4b.

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

     

The name of the program director/principal investigator must be provided at the top of each printed page and each continuation page.

RESEARCH GRANT

TABLE OF CONTENTS


Page Numbers

Face Page


1


Description, Project/Performance Sites, Senior/Key Personnel, Other Significant Contributors, and Human Embryonic Stem Cells


2


Table of Contents


     


Detailed Budget for Initial Budget Period


     


Budget for Entire Proposed Period of Support


     


Budgets Pertaining to Consortium/Contractual Arrangements


     


Biographical Sketch – Program Director/Principal Investigator (Not to exceed five pages each)


     


Other Biographical Sketches (Not to exceed five pages each – See instructions)


     


Resources


     


Checklist


     




Research Plan


     




1. Introduction to Resubmission Application, if applicable, or Introduction to Revision Application,
if applicable *


     


2. Specific Aims *


     


3. Research Strategy *


     


4. Bibliography and References Cited/Progress Report Publication List


     


5. Vertebrate Animals


     


6. Select Agent Research


     


7. Multiple PD/PI Leadership Plan


     


8. Consortium/Contractual Arrangements


     


9. Letters of Support (e.g., Consultants)


     


10. Resource Sharing Plan(s)


     


11. Authentication of Key Biological and/or Chemical Resources


     


12. PHS Human Subjects and Clinical Trials Information


     




Appendix (Two identical CDs.)

Check if

Appendix is

Included

* Follow the page limits for these sections indicated in the application instructions, unless the Funding Opportunity Announcement specifies otherwise.

PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001
Page     Form Page 3


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

     


DETAILED BUDGET FOR INITIAL BUDGET PERIOD

DIRECT COSTS ONLY

FROM

THROUGH

     

     

List PERSONNEL (Applicant organization only)

Use Cal, Acad, or Summer to Enter Months Devoted to Project

Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits


NAME

ROLE ON
PROJECT

Cal.

Mnths

Acad.

Mnths

Summer

Mnths

INST.BASE
SALARY

SALARY
REQUESTED

FRINGE
BENEFITS

TOTAL

     

PD/PI

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Shape1

SUBTOTALS

     

     

     

CONSULTANT COSTS

     

     

EQUIPMENT (Itemize)

     

     

SUPPLIES (Itemize by category)

     

     

TRAVEL

     

     

INPATIENT CARE COSTS      

     

OUTPATIENT CARE COSTS      

     

ALTERATIONS AND RENOVATIONS (Itemize by category)

     

     

OTHER EXPENSES (Itemize by category)

     

     

CONSORTIUM/CONTRACTUAL COSTS

DIRECT COSTS

     

SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)

$

     

CONSORTIUM/CONTRACTUAL COSTS

FACILITIES AND ADMINISTRATIVE COSTS

     

TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD

$

     

PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001 Page     Form Page 4

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

     


BUDGET FOR ENTIRE PROPOSED PROJECT PERIOD
DIRECT COSTS ONLY

BUDGET CATEGORY
TOTALS

INITIAL BUDGET
PERIOD
(from Form Page 4)

2nd ADDITIONAL YEAR OF SUPPORT REQUESTED

3rd ADDITIONAL YEAR OF SUPPORT REQUESTED

4th ADDITIONAL YEAR OF SUPPORT REQUESTED

5th ADDITIONAL YEAR OF SUPPORT REQUESTED

PERSONNEL: Salary and fringe benefits. Applicant organization only.

     

     

     

     

     

CONSULTANT COSTS

     

     

     

     

     

EQUIPMENT

     

     

     

     

     

SUPPLIES

     

     

     

     

     

TRAVEL

     

     

     

     

     

INPATIENT CARE
COSTS

     

     

     

     

     

OUTPATIENT CARE
COSTS

     

     

     

     

     

ALTERATIONS AND
RENOVATIONS

     

     

     

     

     

OTHER EXPENSES

     

     

     

     

     

DIRECT CONSORTIUM/
CONTRACTUAL
COSTS

     

     

     

     

     

SUBTOTAL DIRECT COSTS

(Sum = Item 8a, Face Page)

     

     

     

     

     

F&A CONSORTIUM/
CONTRACTUAL
COSTS

     

     

     

     

     

TOTAL DIRECT COSTS

     

     

     

     

     

TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD

$

     

JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.

     

PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001 Page     Form Page 5

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

     


RESOURCES

Follow the 398 application instructions in Part I, 4.7 Resources.

     

PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001 Page     Resources Format Page

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.

HHS Agreement dated:

     

No Facilities And Administrative Costs Requested.

HHS Agreement being negotiated with

     

Regional Office.

No HHS 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.):

     


PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001 Page     Checklist Form Page


PHS Human Subjects and Clinical Trials Information


Note: the PHS Human Subjects and Clinical Trials Information form is not included in this combined form. See individual form here: http://grants.nih.gov/forms/human-subject-study-form.pdf




DO NOT SUBMIT UNLESS REQUESTED

Renewal Applications Only

ALL PERSONNEL REPORT


Always list the PD/PI(s). In addition, list all other personnel who participated in the project during the current budget period for at least one person month or more, regardless of the source of compensation (a person month equals approximately 160 hours or 8.3% of annualized effort). Use Cal, Acad, or Summer to Enter Months Devoted to Project.

Commons ID

Name

Degree(s)

SSN (last 4 digits)

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

DoB
(MM /YY)

Cal

Acad

Summer

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

PHS 398 (Rev. 03/16 Approved Through 10/31/2018) OMB No. 0925-0001 Page     All Personnel Report Format Page

Mailing address for application

Use this label or a facsimile


All applications and other deliveries to the Center for Scientific Review must come either via courier delivery or via the United States Postal Service (USPS.) Applications delivered by individuals to the Center for Scientific Review will not be accepted.

Applications sent via the USPS EXPRESS or REGULAR MAIL should be sent to the following address:


CENTER FOR SCIENTIFIC REVIEW

NATIONAL INSTITUTES OF HEALTH

6701 ROCKLEDGE DRIVE

ROOM 1040 – MSC 7710

BETHESDA, MD 20892-7710


NOTE: All applications sent via a courier delivery service (non-USPS) should use this address, but CHANGE THE ZIP CODE TO 20817

The telephone number is 301-435-0715. C.O.D. applications will not be accepted.

Shape2




A special label for responding to RFAs is not required.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePHS 398 (Rev. 08/12), OMB No. 0925-0001
SubjectDHHS, Public Health Service Grant Application
AuthorOffice of Extramural Programs
File Modified0000-00-00
File Created2021-01-13

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