Form 11 PHS 2590 Forms

PHS Research Performance Progress Report and Other Post-award Reporting (OD)

Attachment 3 PHS 2590 Forms

PHS 2590

OMB: 0925-0002

Document [doc]
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Form Approved Through 10/31/2018 OMB No. 0925-0002 OMB No. 0925-0001

Department of Health and Human Services

Public Health Services

Review Group

     

Type

     

Activity

     

Grant Number

     

Grant Progress Report

Total Project Period

From:

     

Through:

     

Requested Budget Period

From:

     

Through:

     

1. TITLE OF PROJECT

     

2a. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

(Name and address, street, city, state, zip code)

     

2b. E-MAIL ADDRESS

     

2c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

     

2d. MAJOR SUBDIVISION

     

2e. Tel:      

Fax:      

3a. APPLICANT ORGANIZATION

(Name and address, street, city, state, zip code)

     

3b. Tel:      

Fax:      

3c. DUNS:      

4. ENTITY IDENTIFICATION NUMBER

     

6. HUMAN SUBJECTS No Yes

5. NAME, TITLE AND ADDRESS OF ADMINISTRATIVE OFFICIAL

6a. Research

Exempt

No Yes

If Exempt (“Yes” in 6a):

Exemption No.

     

If Not Exempt (“No” in 6a):

IRB approval date

     

     

6b. Federal Wide Assurance No.      

Tel:      

Fax:      

6c. NIH-Defined Phase III

Clinical Trial No Yes

E-MAIL:      

7. VERTEBRATE ANIMALS No Yes

10. PROJECT/PERFORMANCE SITE(S)

7a. If “Yes,” IACUC approval Date      

Organizational Name:      

7b. Animal Welfare Assurance No.      

DUNS:      

8. COSTS REQUESTED FOR NEXT BUDGET PERIOD

Street 1:      

8a. DIRECT $     

8b. TOTAL $     

Street 2:      

9. INVENTIONS AND PATENTS No Yes


If “Yes, Previously Reported

Not Previously Reported

City:      

County:      

State:      

Province:      

Country:      

Zip/Postal Code:      

Congressional Districts:      

11. NAME AND TITLE OF OFFICIAL SIGNING FOR APPLICANT ORGANIZATION (Item 13)

     

TEL:      

FAX:      

E-MAIL:      

12. Corrections to Page 1 Face Page

     

13. 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 11. (In ink)

DATE

     

PHS 2590 (Rev. 03/16) Face Page Form Page 1

Contact Program Director/Principal Investigator:      


2a. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

(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. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

(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. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

(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. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

(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:

     

PHS 2590 (Rev. 03/16) Face Page-continued Form Page 1-Continued

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

     


DETAILED BUDGET FOR NEXT BUDGET PERIOD – DIRECT COSTS ONLY

FROM

     

THROUGH

     

GRANT NUMBER

     

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

SALARY REQUESTED

FRINGE BENEFITS

TOTALS

     

PD/PI

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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)

     

     

SUBTOTAL DIRECT COSTS FOR NEXT BUDGET PERIOD

$

     

CONSORTIUM/CONTRACTUAL COSTS

DIRECT COSTS

     

CONSORTIUM/CONTRACTUAL COSTS

FACILITIES AND ADMINISTRATIVE COSTS

     

TOTAL DIRECT COSTS FOR NEXT BUDGET PERIOD (Item 8a, Face Page)

$

     

PHS 2590 (Rev. 03/16) Page     Form Page 2

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

     


BUDGET JUSTIFICATION

GRANT NUMBER

     

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. 03/16) Page     Form Page 3

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

     


PROGRESS REPORT SUMMARY

GRANT NUMBER

     

PERIOD COVERED BY THIS REPORT

PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR

     

FROM

     

THROUGH

     

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 PD/PI Leadership Plan

No Change Since Previous Submission

Change

E. Human Embryonic Stem Cell Line(s) Used

No Change Since Previous Submission

Change

SEE PHS 2590 INSTRUCTIONS.


WOMEN AND MINORITY INCLUSION: See PHS 398 Instructions. Use Inclusion Enrollment Report Format Page.

     

PHS 2590 (Rev. 03/16) Page     Form Page 5

Program Director/Principal Investigator (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

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 of the PHS 398, and listed in Part I, 4.1 under Item 14. If unable to certify compliance, where applicable, provide an explanation and place it after the Progress Report (Form Page 5).


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.


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.

HHS Agreement dated:

     

No Facilities and Administrative Costs Requested.

No HHS Agreement, but rate established with

     

Date

     

CALCULATION*

Entire proposed budget period:

Amount of base $

     

x Rate applied

     

% = 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. 03/16) Page     Form Page 6

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

ALL PERSONNEL REPORT


Place this form at the end of the signed original copy of the application. Do not duplicate.

GRANT NUMBER

     


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 the following abbreviated categories for describing Role on Project:

  • PD/PI

  • Statistician

  • Co-Investigator

  • Graduate Student (research assistant)

  • Faculty

  • Non-student Research Assistant

  • Postdoctoral (scholar, fellow, or other

  • Undergraduate Student

postdoctoral position)

  • High School Student

  • Technician

  • Consultant

  • Staff Scientist (doctoral level)

  • Other (please specify)

If personnel are supported by a Reentry or Diversity Supplement please indicate such after the Role on Project, using the following abbreviations:  RS - Reentry Supplement; DS - Diversity Supplement.

Use Cal (calendar), Acad, or Summer to enter months devoted to project.


Commons ID

Name

Degree(s)

SSN (last 4 digits)

Role on Project

DoB
(MM /YY)

Cal

Acad

Summer


     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

     

     

     

    

     

     

    

    

    

0925-0002 (Rev.03/16) Page     Form Page 7

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

     

NEXT BUDGET PERIOD

(Follow instructions carefully)

FROM

     

THROUGH

     

GRANT NUMBER

     

ITEMIZE DIRECT COSTS REQUESTED FOR NEXT BUDGET PERIOD

DOLLAR AMOUNT REQUESTED (omit cents)

PREDOCTORAL STIPENDS (List trainee names)

     


No. Requested:

     

$

     

POSTDOCTORAL STIPENDS (Itemize) (List trainee names and levels)

     


No. Requested:

     

$

     

OTHER STIPENDS (Specify)

     


$

     

TOTAL STIPENDS

$

     

TUITION and FEES (including Health Insurance when applicable – see new Instructions) (Itemize)

(List each category separately)

     


$

     

TRAINEE TRAVEL (Describe)

     


$

     

TRAINING-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. 03/16) Page     Institutional Training Grant Additional Budget Page 2

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









































0925-0002 (Rev. 03/16) Page     Inclusion Enrollment Report Format Page


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

     

Trainee Diversity Report

This report format should NOT be used for data collection from trainees.

Training Grant Title:

     

Total Number of Appointed:

     

Grant Number:

     


PART A. TOTAL TRAINEE APPOINTMENTS REPORT: Number of Trainees Appointed by Ethnicity and Race

Ethnic Category

Females

Males

Sex/Gender Unknown or Not Reported

Total

Hispanic or Latino

     

     

     

     

**

Not Hispanic or Latino

     

     

     

     


Unknown (individuals not reporting ethnicity)

     

     

     

     


Ethnic Category: Total of All Trainees*

     

     

     

     

*

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 Trainees*

     

     

     

     

*


PART B. HISPANIC TRAINEE APPOINTMENTS REPORT: Number of Hispanics or Latinos Appointed

Racial Categories

Females

Males

Sex/Gender 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**

     

     

     

     

**


PART C. TRAINEES WITH DISABILITIES OR FROM DISADVANTAGED BACKGROUNDS

Number of Trainees with Disabilities:

     


Number of Trainees from Disadvantaged Backgrounds:

     


(*) (**) These totals must agree.

0925-0002 (Rev. 03/16) Page     Trainee Diversity Report Format Page

File Typeapplication/msword
File TitlePHS 2590 (Rev. 08/12), Face Page,
SubjectDHHS, Public Health Service Grant Progress Report
AuthorOffice of Extramural Programs
Last Modified ByHarris, Stefanie (NIH/OD) [E]
File Modified2017-01-24
File Created2017-01-24

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