Principal Investigator/Project Director Data

THE UNIVERSITY OF MEMPHIS PROPOSAL SUMMARY FORM

PROJECT TITLE

PRINCIPAL INVESTIGATOR/PROJECT DIRECTOR DATA

Name ______Department/Center ______

Phone ______Fax ______E-mail ______Shared Credit ____ %

Co-PI/PD ______Shared Credit ____ % Co-PI/PD ______Shared Credit ____ %

Department/Center ______Department/Center ______AGENCY TRANSMITTAL DATA Requested Submission Date ______

Sponsor’s Name ______OR

ATTN: ______Required Deadline Date ______

Street Address ______Deadline Type Postmark

Bldg/Room ______Receipt by Sponsor City, State ZIP ______Number of Copies ______Sponsor’s Phone Number ______

BUDGET DATA Year One Total Period (for multi-year projects) AWARD TERMS

Requested Start Date ______Grant Contract (Cost-reimbursable) Requested End Date ______Contract (Fixed-fee) Requested Direct Costs $ ______$ ______Cooperative Agreement Other ______Requested Indirect Costs @______% $ ______$ ______

Total Requested Costs $ ______$ ______

PROPOSAL TYPE ACTIVITY TYPE COST-SHARING YES NO

New Research Amount Source (Acct Number)

Instruction/Training Preliminary $ ______- ______Public Service Renewal/Continuation * $ ______- ______Other Revision $ ______- ______

Subcontracts YES NO $ ______- ______Supplement * included? Current Account Number ___ - ______

SPECIAL REVIEWS Protocol Number Date Approved UNIVERSITY RESOURCES INVOLVED Yes No Use/Renovation of Space Not Currently Available to Project Human Subjects ______Yes No Use of Equipment Not Currently Available to Project Animal Use ______Yes No Use of Electron Microscopy Facilities Biohazards ______Yes No Use of Campus Telecommunication Resources Other (specify) ______Yes No Use of Personnel Not Currently Employed by U of M

INDIRECT COSTS: Exception to the full federal indirect cost rate is requested for ACTIVITY LOCATION: for the following reason: On-Campus State of Tennessee agency @ 15 % Off-Campus* Sponsor allows a maximum of ______% indirect costs as verified by: Sponsor guidelines, page ______(or copy attached) and/or Office of Research Support Services *Off-Campus Definition: For all activities performed in facilities Other (please specify)______not owned by the institution and to which rent is directly allocated to the project. CERTIFICATIONS AND SIGNATURES

POLICIES AND PROCEDURES: By signature below, I certify that I understand that the expenditure of funds received for externally sponsored projects is subject to both sponsor guidelines and The University of Memphis Policies and Procedures. These polices and procedures are available on-line at the following web address: http://policies.memphis.edu/. Assistance in identifying applicable policies and procedures is available from Research Support Services.

CERTIFICATIONS AND ASSURANCES: By signature below, I certify that (a) I am not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from current transactions by a Federal department or agency; (b) I have not and will not lobby any Federal agency on behalf of this project; (c) neither I or my immediate family currently has a business relationship with the sponsor (other than through a sponsored project administered by The University of Memphis) or other possible conflict of interest with regard to this proposal.

FINANCIAL DISCLOSURE: Complete section (below right). See University of Memphis procedure “Disclosure of Financial Interests Related to Federally Sponsored Projects” (2A:18:01A ) at http://policies.memphis.edu/2a1801a.html for complete definition of financial interests.

ALL INVESTIGATORS/PROJECT DIRECTORS MUST SIGN FINANCIAL DISCLOSURE: Do you, your spouse, or dependent children have AND COMPLETE FINANCIAL DISCLOSURE SECTION: any financial interests related to the work to be conducted under the sponsored project?

______Principal Investigator/Project Director Date Yes No

______Yes No Co-Investigator/Project Director Date

______Yes No Co-Investigator/Project Director Date If yes, attach the name of each entity in which you have related financial interest and a description of financial interest for each entity.

DEPARTMENT/COLLEGE APPROVALS

The attached proposal has been reviewed and is consistent with Department and College plans and programs and requires no additional equipment, facilities, personnel time, or supporting services other than outlined in the proposal and/or indicated on this form.

FOR THE PRINCIPAL INVESTIGATOR/PROJECT DIRECTOR

______Department Chair Date Dean Date

FOR CO-INVESTIGATORS/DIRECTORS

______Department Chair Date Dean Date

OTHER APPROVALS (AS NEEDED)

______Signature Date Signature Date

FOR USE BY RESEARCH SUPPORT SERVICES

______Announcement Number CFDA # Received by Date

Underrecovery of Indirect Costs: ______Reviewed by Date

______RSS Proposal Log Number Date ______Approved by Date