Form SBIR/STTR pre-awar SBIR/STTR pre-awar SBIR/STTR pre-award

National Science Foundation NSF SBIR/STTR Administrative Questions
Please respond to these items, including signatures by the Principal Investigator (PI) and the Authorized Organizational Representative (AOR).
Please confirm that the PI will primarily employed (51%) by the applicant small business for the duration of the award. Note that professional/employment obligations in any other capacity, that total more than 19.6 hours per week, are not consistent with the primary employment requirement. Affirm Are there tasks in this proposal that overlap with those in any prior, current, or pending proposal or award involving the company or its personnel? If there are overlapping proposals or awards, please give details of all such projects, as required by the solicitation. Yes No Does the proposing small business have any affiliated companies? If so, please list these companies and explain how the firms are related. For more details: https://www.sbir.gov/affiliation Yes No

4. Outside of their common involvement in the applicant small business, are there any relationships (personal, professional, or financial) between any project or company personnel (this includes subaward participants and consultants), company owners, officers, or employees? If yes, please explain.

Yes No

4. ^{Has the current and pending support information for any person listed as a} “senior person” in the project (or subaward) budget changed since the proposal was submitted? If the answer is yes, please send a list of current and pending support with this form.

Yes No

4. Please provide a list of addresses for all locations where significant research on this SBIR/STTR project will be performed, if awarded. Please note whether each of these facilities is owned by the small business, leased by the small business, or neither of the above. For any of the listed facilities not owned by the small business, please include with your email response lease documentation (if leased) or a signed letter from the facility owner or administrator granting access to the small business.

Address of Facility	Owned/Leased/Other

7. Please provide a list of all company officers and all significant owners (individuals and institutions with more than a 5% equity share) along with their percentage ownership in the company. For each person listed, also please disclose a) any other current employers and b) expected level of effort, in hours per week, which they will commit to small business activities, if this project is awarded.
	Name of individual/institution	Ownership (%)	Company Officer (Y/N)	If an individual, Phase I time commitment (hr/wk)	Other affiliations/employers

8. The project Principal Investigator (PI) and undersigned company officer have viewed a video about the rules and obligations that pertain to a Phase I SBIR/STTR award at https://seedfund.nsf.gov/requirements/ in its entirety and affirm below that they have viewed and understand the full video.

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Affirm

9. The project Principal Investigator (PI) and undersigned company officer have viewed and completed the NSF Research Security Training Condensed Training Module: Training | SECURE Center in its entirety and affirm below that they have viewed and understand the full video.

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Affirm

10. The project Principal Investigator (PI) and undersigned company officer have viewed the three video tutorials from the Small Business Association on Cybersecurity for Small Business in their entirety and affirm below that they have viewed and understand the tutorials.

• The Impact of Cybercrime on Small Business: https://www.sbir.gov/tutorials/cyber-security/tutorial-1

• Introduction to Cyberthreats: https://www.sbir.gov/tutorials/cyber-security/tutorial-2

• Elements of a Small Business Cybersecurity Plan: https://www.sbir.gov/tutorials/cyber-security/tutorial-3

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Affirm

Foreign Influence Disclosures

Relevant Definitions

Covered individual —the term “covered individual” means an individual who—

1. contributes in a substantive, meaningful way to the scientific development or execution of a research and development project proposed to be carried out with a research and development award from a federal research agency; and

2. is designated as a covered individual by the federal research agency concerned.

Foreign affiliation —the term “foreign affiliation” means a funded or unfunded academic, professional, or institutional appointment or position with a foreign government or government-owned entity, whether full- time, part-time, or voluntary. This includes appointments or positions deemed adjunct, visiting, or honorary with research institutions located in a foreign country of concern.

Foreign country of concern —the term “foreign country of concern” means the People's Republic of China, the Democratic People's Republic of Korea, the Russian Federation, the Islamic Republic of Iran, or any other country determined to be a country of concern by the Secretary of State. See https://www.sbir.gov/foreign_disclosures for an updated list of designated countries.

Malign foreign talent recruitment program —the term “malign foreign talent recruitment program” has the meaning given such term in section 19237 of title 42.

Federally funded award —the term “federally funded award” means a Phase I, Phase II (including a Phase II award under subsection (cc)), or Phase III SBIR or STTR award made using a funding agreement.

Disclosure Questions

Responses to disclosure questions may contain trade secrets or commercial or financial information that is privileged or confidential and is exempt from public disclosure. Such information shall be used or disclosed only for evaluation purposes or in accordance with an award between the submitter and the Government. An up-to-date list of countries determined to be countries of concern by the Secretary of State will be maintained and accessible on SBIR.gov.

1. Is any owner or covered individual of the applicant or awardee party to any malign foreign talent recruitment program?

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Yes No

If yes, disclose the first and last name of each owner or covered individual, identify their role (i.e., owner or covered individual), and the malign foreign talent recruitment program.

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2. Is there a parent company, joint venture, or subsidiary, of the applicant or awardee that is based in or receives funding from, any foreign country of concern?
	Yes No
If yes, disclose the name, full address, applicant or awardee relationships ( i.e., parent company, joint venture, or subsidiary) of each entity based in, or funded by, any foreign country of concern. 3. Does the applicant or awardee have any current or pending contractual or financial obligation or other agreement specific to a business arrangement, or joint venture-like arrangement with an enterprise owned by a foreign state or any foreign entity?
	Yes No
If yes, disclose the name of each enterprise or foreign entity, type of obligation, agreement, or arrangement ( i.e., contractual, financial, or other), description of obligation, agreement, or arrangement, and the foreign state(s) and/or the country of the foreign entity (or entities).
4. Is the applicant or awardee wholly owned in a foreign country?
	Yes No
If yes, disclose the foreign country.
5. Does the applicant or awardee have any venture capital or institutional investment? Yes No If yes, proceed to question 5a. If no, proceed to question 6. 5a. Does the investing entity have a general partner or any other individual holding a leadership role who has a foreign affiliation with any foreign country of concern?

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	Yes No Unable to determine
If yes or unable to determine, disclose the venture capital or institutional investing entity's name, the percentage of ownership obtained by the investing entity, and the type of investment ( i.e., equity, debt, or combination of equity and debt).
6. During the previous 5-year period, did the applicant or awardee have any technology licensing or intellectual property sales or transfers, to a foreign country of concern?
	Yes No
If yes, disclose the name, address, and country, of the institution or entity that licensed, purchased, or received the technology or intellectual property.
7. Is there any foreign business entity, offshore entity, or entity outside the United States related to the applicant or awardee?
	Yes No
If yes, disclose the entity name, relationship type ( i.e., foreign business entity, offshore entity, entity outside the United States), description of the relationship to the applicant or awardee, and entity address and country.

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8. Does the applicant or awardee have an owner, officer, or covered individual that has a foreign affiliation with a research institution located in a foreign country of concern?

Yes No

If yes, disclose the first and last name of each owner, officer, or covered individual that has a foreign affiliation with a foreign country of concern, identify their role ( i.e., owner, officer, or covered individual), and the name of the foreign research institution and the foreign country of concern where it is located.

The above information is true and complete, to the best of my knowledge.

1. ^Principal Investigator

Signature: Date Printed Name:

Company Role:

2. Authorized Organizational Representative

Signature: ^Date Printed Name:

Company Role:

NSF Proposal ID #

Instructions for submission:

If you have completed this form using Adobe Reader, please provide your digital signature in the signature field. You may also print, sign, and scan the form and submit via email.

The information requested on this form is pursuant to the National Science Foundation Act of 1950, as amended.  All information you provide is protected under the NSF Act and the Privacy Act of 1974, and will be used only to identify and recruit prospective panelists and reviewers for the specialized and specific programs within the NSF TIP Directorate.   Except for these purposes, this information will not be disclosed except as part of statistical reports or in a form that would not allow identification of individuals.  Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the federal information systems that transmit your data.  Your response is voluntary and failure to provide some or all of the requested information will not in any way adversely affect you.  Persons who send in the Reviewer Information Form may not be invited to review immediately, but this information is retained for future reference in selecting reviewers.

The time needed to complete this form varies according to individual circumstances, but the average time is estimated to be 15 minutes, including the time for reviewing instructions. If you have comments regarding this time estimate, you may write to the National Science Foundation, 2415 Eisenhower Avenue, Alexandria, VA 22314, Attention: NSF Reports Clearance Officer. A federal agency may not conduct or sponsor a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this collection is 3145-0270.